Provider Demographics
NPI:1003978743
Name:BEHAVIOR AND MOOD CLINIC
Entity type:Organization
Organization Name:BEHAVIOR AND MOOD CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-750-9773
Mailing Address - Street 1:1116 N KEDZIE AVE
Mailing Address - Street 2:SUITE 524
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-4152
Mailing Address - Country:US
Mailing Address - Phone:773-750-9773
Mailing Address - Fax:
Practice Address - Street 1:1116 N KEDZIE AVE
Practice Address - Street 2:SUITE 524
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-4152
Practice Address - Country:US
Practice Address - Phone:773-750-9773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty