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General NPI Number Information
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NPI Number | 1881193464
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Entity Type | Organization
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Legal Business Name | SYDNEYMALCOME LLC
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Dates
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Enumeration Date | 02/08/2018
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Last Update Date | 02/08/2018
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Provider Practice Location Address
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Address Line | 307 N MICHIGAN AVE STE 410
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City | CHICAGO
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State | IL
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Zip | 60601-5318
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Country | US
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Telephone | 312-884-1893
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Fax |
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Provider Business Mailing Address
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Address Line | 1420 S MICHIGAN AVE
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City | CHICAGO
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State | IL
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Zip | 60605-2811
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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 | OWNER
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Name | MS. MARION MALCOME
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Credential | LCSW
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Telephone | 312-884-1893
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 149.013372
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License Number State | IL
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