Provider Demographics
NPI:1417318700
Name:CENTER FOR AUTHENTIC LIVING
Entity Type:Organization
Organization Name:CENTER FOR AUTHENTIC LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARI
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHKO
Authorized Official - Suffix:
Authorized Official - Credentials:ND LCPC
Authorized Official - Phone:847-668-4869
Mailing Address - Street 1:120 MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4044
Mailing Address - Country:US
Mailing Address - Phone:847-668-4859
Mailing Address - Fax:
Practice Address - Street 1:120 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4044
Practice Address - Country:US
Practice Address - Phone:847-668-4859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1326241860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty