Provider Demographics
NPI:1598336844
Name:FLUTTERBY VENTURES, LLC
Entity Type:Organization
Organization Name:FLUTTERBY VENTURES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MCKINZIE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-563-0502
Mailing Address - Street 1:3600 N LAKE SHORE DR APT 2608
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4666
Mailing Address - Country:US
Mailing Address - Phone:847-563-0502
Mailing Address - Fax:
Practice Address - Street 1:3600 N LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-4684
Practice Address - Country:US
Practice Address - Phone:847-563-0502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-08
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1528628484Medicaid