Provider Demographics
NPI:1457796385
Name:PRIVATE PRACTICE
Entity Type:Organization
Organization Name:PRIVATE PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MENTAL HEALTH
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-383-4149
Mailing Address - Street 1:76 E 89TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-6607
Mailing Address - Country:US
Mailing Address - Phone:773-383-4149
Mailing Address - Fax:
Practice Address - Street 1:76 E 89TH PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6607
Practice Address - Country:US
Practice Address - Phone:773-383-4149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health