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General NPI Number Information
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NPI Number | 1699171207
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Entity Type | Organization
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Legal Business Name | PSYCHOTHERAPY AND ASSESSMENT OF HYDE PARK
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Dates
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Enumeration Date | 11/10/2014
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Last Update Date | 11/10/2014
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Provider Practice Location Address
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Address Line | 1525 E 55TH ST SUITE 301B
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City | CHICAGO
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State | IL
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Zip | 60615-5512
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Country | US
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Telephone | 773-771-8759
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Fax |
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Provider Business Mailing Address
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Address Line | 1525 E 55TH ST SUITE 301B
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City | CHICAGO
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State | IL
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Zip | 60615-5512
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. THERESA GREGOIRE
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Credential | PSY.D.
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Telephone | 773-771-8759
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.015492
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071007702
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License Number State | IL
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