1003868472 NPI number — AFFILIATES IN COUNSELING LLC

Table of content: (NPI 1003868472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003868472 NPI number — AFFILIATES IN COUNSELING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AFFILIATES IN COUNSELING LLC
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:
THE CENTER FOR DIVORCE RECOVERY
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:
1003868472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 SKOKIE BLVD
Provider Second Line Business Mailing Address:
215
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-4013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-480-0300
Provider Business Mailing Address Fax Number:
847-291-0576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
633 SKOKIE BLVD
Provider Second Line Business Practice Location Address:
260
Provider Business Practice Location Address City Name:
NORTHBROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60062-2858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-480-0300
Provider Business Practice Location Address Fax Number:
847-291-0576
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIRMAN
Authorized Official First Name:
MORTON
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
847-480-0300

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1620796 . This is a "BCBS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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