Provider Demographics
NPI:1568867398
Name:ANDERSONVILLE COUNSELING CENTER, LLC
Entity Type:Organization
Organization Name:ANDERSONVILLE COUNSELING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:III
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-331-4600
Mailing Address - Street 1:5315 N CLARK ST
Mailing Address - Street 2:STE 319
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2290
Mailing Address - Country:US
Mailing Address - Phone:847-331-4600
Mailing Address - Fax:773-409-5590
Practice Address - Street 1:5412 N CLARK ST
Practice Address - Street 2:SUITE 210
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1272
Practice Address - Country:US
Practice Address - Phone:847-331-4600
Practice Address - Fax:773-409-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006239103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty