Provider Demographics
NPI:1154814713
Name:NORTH SHORE PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:NORTH SHORE PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROTBLATT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-323-8189
Mailing Address - Street 1:615 EUCLID CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-1271
Mailing Address - Country:US
Mailing Address - Phone:847-323-8189
Mailing Address - Fax:
Practice Address - Street 1:2502 N CLARK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1850
Practice Address - Country:US
Practice Address - Phone:847-778-5533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008109103TC0700X
IL1490187661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1982122412OtherBCBS-IL
IL1487872735OtherBCBS-IL