Provider Demographics
NPI:1003374638
Name:EQUILIBRIUM, INC
Entity Type:Organization
Organization Name:EQUILIBRIUM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CADC
Authorized Official - Phone:219-743-9017
Mailing Address - Street 1:53 W JACKSON BLVD STE 1119
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-4186
Mailing Address - Country:US
Mailing Address - Phone:312-380-9554
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 1119
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-4186
Practice Address - Country:US
Practice Address - Phone:312-380-9554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-02
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1194113308OtherNPPES