Provider Demographics
NPI:1417197955
Name:CHICAGO CENTER FOR PSYCHOPHYSICAL HEALING
Entity Type:Organization
Organization Name:CHICAGO CENTER FOR PSYCHOPHYSICAL HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:NORTHAGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:LAC
Authorized Official - Phone:773-764-0960
Mailing Address - Street 1:1622 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1214
Mailing Address - Country:US
Mailing Address - Phone:773-764-0960
Mailing Address - Fax:
Practice Address - Street 1:1622 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1214
Practice Address - Country:US
Practice Address - Phone:773-764-0960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000302171100000X
IL198.000412171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty