Basic Information
| Provider Information | |||||||||
| NPI: | 1215153853 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEHAVORIAL HEALTH ASSOCIATES LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2257 | ||||||||
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| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463040357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199268320 | ||||||||
| FaxNumber: | 2199263524 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 S MICHIGAN AVE | ||||||||
| Address2: | STE 1203 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606033357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737103493 | ||||||||
| FaxNumber: | 3127819594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BOCKIAN | ||||||||
| AuthorizedOfficialFirstName: | NEIL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7737103493 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0700X | 071-005194 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging |
ID Information
| ID | Type | State | Issuer | Description | 14-1854431 | 01 | IL | FEDERAL TAX ID | OTHER |