Provider Demographics
NPI:1073804720
Name:REALITY TALK, INC
Entity Type:Organization
Organization Name:REALITY TALK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-328-3571
Mailing Address - Street 1:1507 E 53RD ST
Mailing Address - Street 2:#275
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-4573
Mailing Address - Country:US
Mailing Address - Phone:630-328-3571
Mailing Address - Fax:
Practice Address - Street 1:1808 S STATE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1611
Practice Address - Country:US
Practice Address - Phone:312-949-1340
Practice Address - Fax:312-949-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-085290261Q00000X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF38494Medicare UPIN