Provider Demographics
NPI:1003161225
Name:OAK PARK BEHAVIORAL MEDICINE LLC
Entity Type:Organization
Organization Name:OAK PARK BEHAVIORAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAFT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:312-725-6175
Mailing Address - Street 1:824 S GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1125
Mailing Address - Country:US
Mailing Address - Phone:312-725-6175
Mailing Address - Fax:
Practice Address - Street 1:818 HARRISON ST
Practice Address - Street 2:SUITE 210
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1144
Practice Address - Country:US
Practice Address - Phone:312-725-6175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-14
Last Update Date:2012-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008285103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty