Provider Demographics
NPI:1174845291
Name:MARY AND TOM LEO ASSOCIATES, INC.
Entity Type:Organization
Organization Name:MARY AND TOM LEO ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:MOIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:773-267-5795
Mailing Address - Street 1:2656 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1559
Mailing Address - Country:US
Mailing Address - Phone:773-267-5795
Mailing Address - Fax:773-267-4787
Practice Address - Street 1:2656 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1559
Practice Address - Country:US
Practice Address - Phone:773-267-5795
Practice Address - Fax:773-267-4787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health