Provider Demographics
NPI:1467643791
Name:EMBOLDEN CLINICAL SERVICES
Entity Type:Organization
Organization Name:EMBOLDEN CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:BOWLING
Authorized Official - Suffix:
Authorized Official - Credentials:HD
Authorized Official - Phone:630-510-3248
Mailing Address - Street 1:1755 S NAPERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-8144
Mailing Address - Country:US
Mailing Address - Phone:630-510-3248
Mailing Address - Fax:
Practice Address - Street 1:1755 S NAPERVILLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-8144
Practice Address - Country:US
Practice Address - Phone:630-510-3248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043857OtherCIGNA
206272OtherMANAGED HEALTH NETWORK
02220198OtherBLUE CROSS BLUE SHIELD
144300OtherCOMPSYCHE
5777746OtherAETNA
1043857OtherCIGNA
5777746OtherAETNA