MEDICARE: FOR REAL THERAPY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1114554722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOR REAL THERAPY INC

Provider Business Mailing Address
First Line	:	1951 W SUNNYSIDE AVE APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5861
Country	:	US
Telephone Number	:	954-559-0073
Fax Number	:

Provider Business Practice Location Address
First Line	:	1564 N DAMEN AVE STE 208
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2102
Country	:	US
Telephone Number	:	773-888-1681
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL SUPERVISOR
Name	:	DR. FABRICE ROBERT LUBIN
Credential	:	PSYD
Telephone Number	:	773-888-1681

Provider Enumeration Date	:	03/24/2020
Last Update Date	:	03/24/2020

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