Provider Demographics
NPI:1619758836
Name:SPECIALIZED FORENSIC UNIT PC
Entity Type:Organization
Organization Name:SPECIALIZED FORENSIC UNIT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TETYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTYSHYNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-488-2604
Mailing Address - Street 1:303 N 2ND ST STE 22
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1804
Mailing Address - Country:US
Mailing Address - Phone:312-818-9300
Mailing Address - Fax:
Practice Address - Street 1:1005 N WESTERN AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-6224
Practice Address - Country:US
Practice Address - Phone:800-488-9790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health