Provider Demographics
NPI:1962032086
Name:BUCKTOWN THERAPY
Entity Type:Organization
Organization Name:BUCKTOWN THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:920-418-1165
Mailing Address - Street 1:3125 W FULLERTON AVE APT 212
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6959
Mailing Address - Country:US
Mailing Address - Phone:920-418-1165
Mailing Address - Fax:
Practice Address - Street 1:1820 W WEBSTER AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2934
Practice Address - Country:US
Practice Address - Phone:630-733-8595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health