1053516203 NPI number — FAMILY STRESS CLINIC

Table of content: (NPI 1053516203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053516203 NPI number — FAMILY STRESS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY STRESS CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLIFFORD BRICKMAN
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053516203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 N LAKE SHORE DR
Provider Second Line Business Mailing Address:
#2215
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60657-6232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-935-3500
Provider Business Mailing Address Fax Number:
773-472-1022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 N MICHIGAN AVE
Provider Second Line Business Practice Location Address:
#1729
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60602-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-935-3500
Provider Business Practice Location Address Fax Number:
773-472-1022
Provider Enumeration Date:
06/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRICKMAN
Authorized Official First Name:
CLIFFORD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR THERAPIST
Authorized Official Telephone Number:
773-935-3500

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  149000523 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 172P00000X , with the licence number: 181000295 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01617791 . This is a "BLUECROSS-BLUESHIELD #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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