Basic Information
| Provider Information | |||||||||
| NPI: | 1548305055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALBAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 W. 21ST PLACE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606085507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738477993 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1414 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601603902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086810073 | ||||||||
| FaxNumber: | 7086813958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.