MEDICARE: CHICAGO COLLABORATIVE PSYCHOTHERAPY, LLC

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	071.009604	IL

General Provider Information

NPI Number	:	1396242350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO COLLABORATIVE PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	4861 N PAULINA ST APT 2A
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-4110
Country	:	US
Telephone Number	:	312-834-7014
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 N MICHIGAN AVE STE 1660
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-6022
Country	:	US
Telephone Number	:	312-834-7014
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	MICHAEL MORIN
Credential	:	PH.D.
Telephone Number	:	312-834-7014

Provider Enumeration Date	:	04/06/2018
Last Update Date	:	04/06/2018

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