Provider Demographics
NPI:1013316470
Name:FAMILY BUILDING BLOCKS
Entity Type:Organization
Organization Name:FAMILY BUILDING BLOCKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCPC
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:773-429-9454
Mailing Address - Street 1:10450 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2508
Mailing Address - Country:US
Mailing Address - Phone:773-429-9454
Mailing Address - Fax:
Practice Address - Street 1:10450 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2508
Practice Address - Country:US
Practice Address - Phone:773-429-9454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1825273252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency