MEDICARE: INSTITUTE FOR BEHAVIORAL HEALTH PC

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	2084P0800X	Psychiatry Physician		IL

General Provider Information

NPI Number	:	1417154378
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTITUTE FOR BEHAVIORAL HEALTH PC

Provider Business Mailing Address
First Line	:	4250 N MARINE DR APT 1521
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1714
Country	:	US
Telephone Number	:	773-404-0160
Fax Number	:

Provider Business Practice Location Address
First Line	:	1373 W CHICAGO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-5761
Country	:	US
Telephone Number	:	773-477-1872
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DIANA YATES
Credential	:	LCSW
Telephone Number	:	773-404-0160

Provider Enumeration Date	:	07/02/2007
Last Update Date	:	12/06/2007

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