Provider Demographics
NPI:1235430612
Name:PHC OF BUFFALO GROVE CLINICAL PSYCHOLOGY
Entity Type:Organization
Organization Name:PHC OF BUFFALO GROVE CLINICAL PSYCHOLOGY
Other - Org Name:PORTRAIT HEALTH CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-868-3435
Mailing Address - Street 1:175 E HAWTHORN PKWY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1463
Mailing Address - Country:US
Mailing Address - Phone:847-868-3435
Mailing Address - Fax:847-859-5885
Practice Address - Street 1:175 E HAWTHORN PKWY
Practice Address - Street 2:SUITE 235
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1463
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:847-859-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007099103T00000X
IL164005333133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8165Medicare UPIN