MEDICARE: ANDERSONVILLE COUNSELING CENTER, 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	103T00000X	Psychologist	071006239	IL

General Provider Information

NPI Number	:	1568867398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDERSONVILLE COUNSELING CENTER, LLC

Provider Business Mailing Address
First Line	:	5315 N CLARK ST
Second Line	:	STE 319
City	:	CHICAGO
State	:	IL
Zip	:	60640-2290
Country	:	US
Telephone Number	:	847-331-4600
Fax Number	:	773-409-5590

Provider Business Practice Location Address
First Line	:	5412 N CLARK ST
Second Line	:	SUITE 210
City	:	CHICAGO
State	:	IL
Zip	:	60640-1272
Country	:	US
Telephone Number	:	847-331-4600
Fax Number	:	773-409-5590

Authorized Official
Title or Position	:	CHIEF PSYCHOLOGIST
Name	:	DR. ROBERT T BAKER III
Credential	:	PSY.D.
Telephone Number	:	847-331-4600

Provider Enumeration Date	:	10/22/2014
Last Update Date	:	10/22/2014

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