=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750765582
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL SERVICES FOR ANXIETY-RELATED DISORDERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2015
-----------------------------------------------------
Last Update Date | 07/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1121 ALEXANDRIA DR
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-9507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-991-9053
-----------------------------------------------------
Fax | 815-991-9483
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 771
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-0700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-991-9053
-----------------------------------------------------
Fax | 815-991-9483
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BENJAMIN HARRIS
-----------------------------------------------------
Credential | MA, LCPC
-----------------------------------------------------
Telephone | 815-991-9053
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180007751
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------