MEDICARE: WISE BEHAVIORAL HEALTH SERVICES LTD

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	103TP2701X	Group Psychotherapy Psychologist		IL

General Provider Information

NPI Number	:	1710162862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE BEHAVIORAL HEALTH SERVICES LTD

Provider Business Mailing Address
First Line	:	9012 S CRANDON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-3807
Country	:	US
Telephone Number	:	773-375-8741
Fax Number	:	773-375-8748

Provider Business Practice Location Address
First Line	:	9012 S CRANDON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-3807
Country	:	US
Telephone Number	:	773-375-8741
Fax Number	:	773-375-8748

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. CHARLES TRIPP
Credential	:
Telephone Number	:	773-510-6165

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	01/08/2008

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