Provider Demographics
NPI:1518142918
Name:CENTER FOR LIFE BALANCE
Entity Type:Organization
Organization Name:CENTER FOR LIFE BALANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON-SKOOG
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:312-332-3344
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:#703
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-332-3344
Mailing Address - Fax:312-332-3844
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:#703
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-332-3344
Practice Address - Fax:312-332-3844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
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
IL206286Medicare PIN