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General NPI Number Information
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NPI Number | 1861780025
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Entity Type | Organization
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Legal Business Name | PAUL J. DETAEGE, LCSW, P.C.
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Dates
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Enumeration Date | 07/20/2011
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Last Update Date | 07/20/2011
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Provider Practice Location Address
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Address Line | 5215 N RAVENSWOOD AVE SUITE 314
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City | CHICAGO
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State | IL
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Zip | 60640-1668
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Country | US
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Telephone | 773-988-4965
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Fax |
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Provider Business Mailing Address
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Address Line | 5215 N RAVENSWOOD AVE SUITE 314
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City | CHICAGO
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State | IL
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Zip | 60640-1668
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Country | US
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Telephone | 773-988-4965
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. PAUL J DETAEGE
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Credential | LCSW
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Telephone | 773-988-4965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 149008180
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License Number State | IL
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