Provider Demographics
NPI:1548753940
Name:DR. DAMITA LARUE & ASSOCIATES, INC.
Entity Type:Organization
Organization Name:DR. DAMITA LARUE & ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMITA
Authorized Official - Middle Name:
Authorized Official - Last Name:LARUE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, FT
Authorized Official - Phone:773-609-2069
Mailing Address - Street 1:5547 N RAVENSWOOD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1125
Mailing Address - Country:US
Mailing Address - Phone:773-609-2069
Mailing Address - Fax:
Practice Address - Street 1:5547 N RAVENSWOOD AVE STE 103
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1125
Practice Address - Country:US
Practice Address - Phone:773-609-2069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty