Provider Demographics
NPI:1295226736
Name:SPRINGPSYCH SERVICES LLC
Entity type:Organization
Organization Name:SPRINGPSYCH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:239-248-7437
Mailing Address - Street 1:1441 W ELMDALE AVE APT 1S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2405
Mailing Address - Country:US
Mailing Address - Phone:239-248-7437
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE STE 529
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3491
Practice Address - Country:US
Practice Address - Phone:312-629-5075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009689103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty