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General NPI Number Information
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NPI Number | 1962032086
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Entity Type | Organization
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Legal Business Name | BUCKTOWN THERAPY
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Dates
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Enumeration Date | 01/16/2020
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Last Update Date | 01/16/2020
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Provider Practice Location Address
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Address Line | 1820 W WEBSTER AVE STE 200
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City | CHICAGO
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State | IL
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Zip | 60614-2934
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Country | US
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Telephone | 630-733-8595
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Fax |
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Provider Business Mailing Address
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Address Line | 3125 W FULLERTON AVE APT 212
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City | CHICAGO
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State | IL
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Zip | 60647-6959
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Country | US
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Telephone | 920-418-1165
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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 | KRISTIN RIDDER
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Credential | PHD
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Telephone | 920-418-1165
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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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