MEDICARE: CHICAGO PSYCHOLOGICAL HEALTH 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	103TC0700X	Clinical Psychologist	180008478	IL

General Provider Information

NPI Number	:	1912332776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO PSYCHOLOGICAL HEALTH CENTER, LLC

Provider Business Mailing Address
First Line	:	2518 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2782
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2518 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2782
Country	:	US
Telephone Number	:	773-469-6675
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	THOMAS ALCOCK
Credential	:
Telephone Number	:	773-469-6675

Provider Enumeration Date	:	09/11/2013
Last Update Date	:	09/11/2013

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