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General NPI Number Information
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NPI Number | 1821516931
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Entity Type | Organization
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Legal Business Name | MIDDLE PATH PSYCHOTHERAPY, LLC
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Dates
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Enumeration Date | 09/08/2017
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Last Update Date | 09/08/2017
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Provider Practice Location Address
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Address Line | 1010 LAKE ST STE 614
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City | OAK PARK
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State | IL
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Zip | 60301-1136
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Country | US
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Telephone | 708-613-0344
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Fax |
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Provider Business Mailing Address
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Address Line | 1010 LAKE ST STE 614
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City | OAK PARK
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State | IL
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Zip | 60301-1136
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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 | PRESIDENT
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Name | DR. JESSICA PUNZO
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Credential |
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Telephone | 708-613-0344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 071.009047
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License Number State | IL
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