Provider Demographics
NPI:1790854636
Name:KEITH V BJORGE PSYD PC
Entity Type:Organization
Organization Name:KEITH V BJORGE PSYD PC
Other - Org Name:CROSSROADS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:V
Authorized Official - Last Name:BJORGE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:815-578-4222
Mailing Address - Street 1:61 S OLD RAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-3127
Mailing Address - Country:US
Mailing Address - Phone:815-578-4222
Mailing Address - Fax:847-438-0844
Practice Address - Street 1:61 S OLD RAND RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-3127
Practice Address - Country:US
Practice Address - Phone:815-578-4222
Practice Address - Fax:847-438-0844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2091057103T00000X
IL071005483103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty