Provider Demographics
NPI:1700389152
Name:POWER
Entity Type:Organization
Organization Name:POWER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LATEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:EDS
Authorized Official - Phone:630-398-6204
Mailing Address - Street 1:605 PICCADILLY LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:682 W BOUGHTON RD STE D
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2199
Practice Address - Country:US
Practice Address - Phone:630-398-6204
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty