Provider Demographics
NPI:1811398621
Name:DR. RACHEL PORT LLC
Entity Type:Organization
Organization Name:DR. RACHEL PORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PORT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:872-233-8456
Mailing Address - Street 1:2835 N SHEFFIELD AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2835 N SHEFFIELD AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5081
Practice Address - Country:US
Practice Address - Phone:872-233-8456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008035251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health