Provider Demographics
NPI:1679832216
Name:PSYCHOLOGICAL SERVICES OF CHICAGO LTD
Entity Type:Organization
Organization Name:PSYCHOLOGICAL SERVICES OF CHICAGO LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:312-909-6766
Mailing Address - Street 1:1300 W BELMONT AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:312-909-6766
Mailing Address - Fax:773-227-4773
Practice Address - Street 1:1300 W BELMONT AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:312-909-6766
Practice Address - Fax:773-227-4773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007551103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty