Provider Demographics
NPI:1457479503
Name:MODIFY, P.C.
Entity Type:Organization
Organization Name:MODIFY, P.C.
Other - Org Name:BUSCH & LAWM CLINICAL SERVICES, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:BUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:630-753-9800
Mailing Address - Street 1:2272 95TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8944
Mailing Address - Country:US
Mailing Address - Phone:630-753-9800
Mailing Address - Fax:630-753-9798
Practice Address - Street 1:2272 95TH ST STE 305
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8944
Practice Address - Country:US
Practice Address - Phone:630-753-9800
Practice Address - Fax:630-753-9798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IL071005399103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09923724OtherBLUE CROSS BLUE SHIELD