Provider Demographics
NPI:1720441124
Name:OAK ROOTS DYNAMIC CORP
Entity Type:Organization
Organization Name:OAK ROOTS DYNAMIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORSO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:224-436-7392
Mailing Address - Street 1:675 N NORTH CT
Mailing Address - Street 2:SUITE 272
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-8157
Mailing Address - Country:US
Mailing Address - Phone:224-436-7392
Mailing Address - Fax:847-398-7831
Practice Address - Street 1:675 N NORTH CT
Practice Address - Street 2:SUITE 272
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-8157
Practice Address - Country:US
Practice Address - Phone:224-436-7392
Practice Address - Fax:847-398-7831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.012248251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health