Provider Demographics
NPI:1164125621
Name:WOODSTOCK THERAPIST LLC
Entity Type:Organization
Organization Name:WOODSTOCK THERAPIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-236-3272
Mailing Address - Street 1:665 TOLLGATE RD STE B
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-9353
Mailing Address - Country:US
Mailing Address - Phone:815-236-3272
Mailing Address - Fax:
Practice Address - Street 1:665 TOLLGATE RD STE B
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-9353
Practice Address - Country:US
Practice Address - Phone:815-236-3272
Practice Address - Fax:844-734-1259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health