Provider Demographics
NPI:1396505418
Name:MB BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:MB BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-307-5023
Mailing Address - Street 1:7712 KNOTTY PINE CT
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2912
Mailing Address - Country:US
Mailing Address - Phone:773-307-5023
Mailing Address - Fax:
Practice Address - Street 1:7712 KNOTTY PINE CT
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2912
Practice Address - Country:US
Practice Address - Phone:773-307-5023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty