Provider Demographics
NPI:1295007318
Name:PALOS PSYCHOTHERAPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PALOS PSYCHOTHERAPY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCPC
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUECKHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:708-364-7272
Mailing Address - Street 1:7330 W COLLEGE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7330 W COLLEGE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1157
Practice Address - Country:US
Practice Address - Phone:708-364-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-05
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490104861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty