1720812860 NPI number — ALZA GREAT LAKES PSYCHOTHERAPY PROFESSIONAL LLC

Table of content: (NPI 1720812860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720812860 NPI number — ALZA GREAT LAKES PSYCHOTHERAPY PROFESSIONAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALZA GREAT LAKES PSYCHOTHERAPY PROFESSIONAL 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:
Provider Other Organization Name Type Code:
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:
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NPI Number Information

NPI Number:
1720812860
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7061 NORTH AVE # 292
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60302-1015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-824-7533
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1719 N RUTHERFORD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60707-3942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-824-7533
Provider Business Practice Location Address Fax Number:
312-748-4256
Provider Enumeration Date:
08/30/2024

Additional Information

Authorized Official

Authorized Official Last Name:
MILLLWARD
Authorized Official First Name:
ENA
Authorized Official Middle Name:
ISIS
Authorized Official Title or Position:
LCSW
Authorized Official Telephone Number:
773-707-6093

Provider Taxonomy Codes

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

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





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