Provider Demographics
NPI:1457685604
Name:STATE OF MIND MENTAL HEALTH & CONSULTATION SERVICES P.C.
Entity Type:Organization
Organization Name:STATE OF MIND MENTAL HEALTH & CONSULTATION SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LATANYA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-807-2144
Mailing Address - Street 1:17911 LOS ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-1509
Mailing Address - Country:US
Mailing Address - Phone:708-798-4510
Mailing Address - Fax:
Practice Address - Street 1:400 E 41ST ST
Practice Address - Street 2:SUITE 101A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3071
Practice Address - Country:US
Practice Address - Phone:773-285-0804
Practice Address - Fax:773-285-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006065251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health