Provider Demographics
NPI:1396735361
Name:PSYCHOLOGY CENTER P.C.
Entity type:Organization
Organization Name:PSYCHOLOGY CENTER P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:708-974-4274
Mailing Address - Street 1:10713 W DORIC CIRCLE
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-2220
Mailing Address - Country:US
Mailing Address - Phone:773-238-2828
Mailing Address - Fax:708-974-3845
Practice Address - Street 1:10343 S WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2410
Practice Address - Country:US
Practice Address - Phone:773-238-2828
Practice Address - Fax:708-974-3845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060005211103T00000X
IL071003666103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL345365834001Medicaid
IL345365834001Medicaid
ILIL7074Medicare PIN
IL345365834001Medicaid