Provider Demographics
NPI:1811374309
Name:PRIVATE PRACTICE
Entity Type:Organization
Organization Name:PRIVATE PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:REINECKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:786-269-6864
Mailing Address - Street 1:1524 W WINNEMAC AVE
Mailing Address - Street 2:APT. 7
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2850
Mailing Address - Country:US
Mailing Address - Phone:786-269-6864
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1002
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:786-269-6864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149015655261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health