MEDICARE: THE BEHAVIORAL HEALTH COOPERATIVE, 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

General Provider Information

NPI Number	:	1497428817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BEHAVIORAL HEALTH COOPERATIVE, LLC

Provider Business Mailing Address
First Line	:	160 E GRAND AVE STE 500
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3800
Country	:	US
Telephone Number	:	847-686-0090
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 E GRAND AVE STE 500
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3800
Country	:	US
Telephone Number	:	847-686-0090
Fax Number	:

Authorized Official
Title or Position	:	DR/CO-OWNER
Name	:	DR. MERYL PANKHURST
Credential	:	PSYD
Telephone Number	:	847-686-0090

Provider Enumeration Date	:	07/30/2021
Last Update Date	:	05/30/2023

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