Basic Information
| Provider Information | |||||||||
| NPI: | 1235430612 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHC OF BUFFALO GROVE CLINICAL PSYCHOLOGY | ||||||||
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| OtherOrganizationName: | PORTRAIT HEALTH CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E HAWTHORN PKWY | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 E HAWTHORN PKWY | ||||||||
| Address2: | SUITE 235 | ||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2010 | ||||||||
| LastUpdateDate: | 09/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | WARNER | ||||||||
| AuthorizedOfficialFirstName: | JEREMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8478683435 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164005333 | IL | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 103T00000X | 071007099 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.