Provider Demographics
NPI:1609243856
Name:HUMBOLDT BEHAVIORAL HEALTH GROUP
Entity Type:Organization
Organization Name:HUMBOLDT BEHAVIORAL HEALTH GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAHOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:312-659-0020
Mailing Address - Street 1:3317 W LE MOYNE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-2452
Mailing Address - Country:US
Mailing Address - Phone:312-659-0020
Mailing Address - Fax:
Practice Address - Street 1:3317 W LE MOYNE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-2452
Practice Address - Country:US
Practice Address - Phone:312-659-0020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008046103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL468001Medicare UPIN