Provider Demographics
NPI:1558923789
Name:OLD OAK PSYCHOLOGICAL HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:OLD OAK PSYCHOLOGICAL HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, PSYD
Authorized Official - Phone:847-999-3888
Mailing Address - Street 1:401 E PROSPECT AVE STE 218
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3396
Mailing Address - Country:US
Mailing Address - Phone:847-999-3888
Mailing Address - Fax:
Practice Address - Street 1:401 E PROSPECT AVE STE 218
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3396
Practice Address - Country:US
Practice Address - Phone:847-999-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-09
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health