Provider Demographics
NPI:1609198878
Name:EDEGWOOD CLINCIAL SERVICES
Entity Type:Organization
Organization Name:EDEGWOOD CLINCIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINCIAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-962-6731
Mailing Address - Street 1:1288 RICKERT DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-0951
Mailing Address - Country:US
Mailing Address - Phone:630-428-7890
Mailing Address - Fax:
Practice Address - Street 1:1288 RICKERT DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-0951
Practice Address - Country:US
Practice Address - Phone:630-428-7890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-15
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.012640251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health