Provider Demographics
NPI:1184165383
Name:CHICAGO PSYCH THERAPY GROUP, INC.
Entity type:Organization
Organization Name:CHICAGO PSYCH THERAPY GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DORNAK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:312-781-2850
Mailing Address - Street 1:828 DAVIS ST STE 213
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4420
Mailing Address - Country:US
Mailing Address - Phone:312-781-2850
Mailing Address - Fax:847-972-6445
Practice Address - Street 1:828 DAVIS ST STE 213
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4420
Practice Address - Country:US
Practice Address - Phone:312-781-2850
Practice Address - Fax:847-972-6445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TC0700X, 1041C0700X, 225700000X
IL071009088103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty