Provider Demographics
NPI:1083207872
Name:STEPHANIE ROYAL CLINIC LLC
Entity Type:Organization
Organization Name:STEPHANIE ROYAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYAL
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:917-204-5198
Mailing Address - Street 1:47 W POLK ST STE 172
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2000
Mailing Address - Country:US
Mailing Address - Phone:917-204-5198
Mailing Address - Fax:
Practice Address - Street 1:8239 S KING DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-4961
Practice Address - Country:US
Practice Address - Phone:917-204-5198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty