=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700539681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACK EXCELLENCE PSYCHOTHERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2022
-----------------------------------------------------
Last Update Date | 10/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30047 N WAUKEGAN RD
-----------------------------------------------------
City | LAKE BLUFF
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60044-1023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-342-4986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30047 N WAUKEGAN RD
-----------------------------------------------------
City | LAKE BLUFF
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60044-1023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | FITZGERALD AJOKU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 914-609-1183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------