=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700259819
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANGE PERSPECTIVES PSYCHOLOGICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2015
-----------------------------------------------------
Last Update Date | 11/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 LAKE COOK RD 270
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-4920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-416-2966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 770 LAKE COOK RD 270
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-4920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-416-2966
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. XIMENA M TORRES
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 847-416-2966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071008296
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------