Provider Demographics
NPI:1255197042
Name:DR DAMITA LARUE PSYCHOLOGY PLLC
Entity type:Organization
Organization Name:DR DAMITA LARUE PSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO & CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMITA
Authorized Official - Middle Name:SUNWOLF
Authorized Official - Last Name:LARUE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:907-764-2291
Mailing Address - Street 1:1417 W HOLLYWOOD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-4483
Mailing Address - Country:US
Mailing Address - Phone:907-764-2291
Mailing Address - Fax:773-634-8112
Practice Address - Street 1:1417 W HOLLYWOOD AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4483
Practice Address - Country:US
Practice Address - Phone:907-764-2291
Practice Address - Fax:773-634-8112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty