Provider Demographics
NPI:1710225644
Name:TRANSFORMATION BEHAVIORAL HEALTH ASSOCIATES LLC
Entity Type:Organization
Organization Name:TRANSFORMATION BEHAVIORAL HEALTH ASSOCIATES LLC
Other - Org Name:CREATIVE ALTERNATIVES FOR PSYCHOLOGICAL GROWTH LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:VINEHOUT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:815-245-6669
Mailing Address - Street 1:PO BOX 1861
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-1861
Mailing Address - Country:US
Mailing Address - Phone:815-245-6669
Mailing Address - Fax:815-334-1640
Practice Address - Street 1:1090 MCCONNELL RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7310
Practice Address - Country:US
Practice Address - Phone:815-245-6669
Practice Address - Fax:815-334-1640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006683103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11894012OtherCAQH
IL600016119OtherMAGELLAN
IL35641736OtherBCBS
IL4391Medicare PIN
IL600016119OtherMAGELLAN
IL578551OtherVALUE OPTIONS