Provider Demographics
NPI:1629380290
Name:MIND WELL PSYCHOLOGICAL SERVICES, LLC.
Entity Type:Organization
Organization Name:MIND WELL PSYCHOLOGICAL SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:Q
Authorized Official - Last Name:CHAIB
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-466-6443
Mailing Address - Street 1:648 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4829
Mailing Address - Country:US
Mailing Address - Phone:708-466-6443
Mailing Address - Fax:
Practice Address - Street 1:9290 FOREST EDGE DR
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-6680
Practice Address - Country:US
Practice Address - Phone:708-466-6443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-11
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007814103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA734AMedicare PIN