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NPI Code Detail

MEDICARE: PROFESSIONAL SERVICES FOR ANXIETY-RELATED DISORDERS, LLC

MEDICARE: PROFESSIONAL SERVICES FOR ANXIETY-RELATED DISORDERS, 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
1101YP2500XProfessional Counselor180007751IL

General Provider Information

NPI Number : 1750765582
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROFESSIONAL SERVICES FOR ANXIETY-RELATED DISORDERS, LLC
Provider Business Mailing Address
First Line : PO BOX 771
Second Line :
City : SYCAMORE
State : IL
Zip : 60178-0700
Country : US
Telephone Number : 815-991-9053
Fax Number : 815-991-9483
Provider Business Practice Location Address
First Line : 1121 ALEXANDRIA DR
Second Line :
City : SYCAMORE
State : IL
Zip : 60178-9507
Country : US
Telephone Number : 815-991-9053
Fax Number : 815-991-9483
Authorized Official
Title or Position : PRESIDENT
Name : BENJAMIN HARRIS
Credential : MA, LCPC
Telephone Number : 815-991-9053
Provider Enumeration Date : 07/10/2015
Last Update Date : 07/10/2015

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