1255577359 NPI number — LIFESPAN COUNSELING AND PSYCHOLOGICAL SERVICES, LLP

Table of content: (NPI 1255577359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255577359 NPI number — LIFESPAN COUNSELING AND PSYCHOLOGICAL SERVICES, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESPAN COUNSELING AND PSYCHOLOGICAL SERVICES, LLP
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:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
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Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1255577359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6645 NORTH AVE
Provider Second Line Business Mailing Address:
UPPER LEVEL
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60302-1057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-386-5080
Provider Business Mailing Address Fax Number:
708-386-5099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6645 NORTH AVE
Provider Second Line Business Practice Location Address:
UPPER LEVEL
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60302-1057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-386-5080
Provider Business Practice Location Address Fax Number:
708-386-5099
Provider Enumeration Date:
12/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MORRISON
Authorized Official First Name:
ORSON
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST OWNER
Authorized Official Telephone Number:
312-307-6554

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071006882 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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