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General NPI Number Information
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NPI Number | 1821540428
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Entity Type | Organization
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Legal Business Name | CHICAGO BEHAVIORAL CLINIC LLC
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Dates
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Enumeration Date | 10/29/2016
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Last Update Date | 06/01/2020
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Provider Practice Location Address
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Address Line | 2502 N CLARK ST STE 206
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City | CHICAGO
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State | IL
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Zip | 60614-1850
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Country | US
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Telephone | 773-850-0294
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Fax |
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Provider Business Mailing Address
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Address Line | 2502 N CLARK ST STE 206
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City | CHICAGO
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State | IL
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Zip | 60614-1850
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Country | US
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Telephone | 773-850-0294
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. AZADEH GHAFFARI
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Credential | PH.D.
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Telephone | 773-850-0294
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071008535
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License Number State | IL
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