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General NPI Number Information
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NPI Number | 1922697143
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Entity Type | Organization
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Legal Business Name | PRIDE ROC
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Dates
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Enumeration Date | 01/12/2021
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Last Update Date | 01/12/2021
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Provider Practice Location Address
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Address Line | 765 W 69TH ST
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City | CHICAGO
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State | IL
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Zip | 60621-2435
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Country | US
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Telephone | 312-860-9552
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 15232
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City | CHICAGO
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State | IL
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Zip | 60615-5141
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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 | LEAD CLINICIAN
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Name | BENJAMIN DURCHSLAG
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Credential |
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Telephone | 312-860-9552
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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 |
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License Number State |
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