Provider Demographics
NPI:1922369941
Name:ADVANCE POTENTIAL PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:ADVANCE POTENTIAL PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/EXCUTIVE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:AUGUST
Authorized Official - Last Name:SEVIER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-512-8813
Mailing Address - Street 1:2007 W GREENLEAF AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3509
Mailing Address - Country:US
Mailing Address - Phone:773-512-8813
Mailing Address - Fax:773-743-7696
Practice Address - Street 1:2007 W GREENLEAF AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-3509
Practice Address - Country:US
Practice Address - Phone:773-512-8813
Practice Address - Fax:773-743-7696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL492722592001Medicaid