Provider Demographics
NPI:1750765582
Name:PROFESSIONAL SERVICES FOR ANXIETY-RELATED DISORDERS, LLC
Entity type:Organization
Organization Name:PROFESSIONAL SERVICES FOR ANXIETY-RELATED DISORDERS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC
Authorized Official - Phone:815-991-9053
Mailing Address - Street 1:PO BOX 771
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-0700
Mailing Address - Country:US
Mailing Address - Phone:815-991-9053
Mailing Address - Fax:815-991-9483
Practice Address - Street 1:1121 ALEXANDRIA DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-9507
Practice Address - Country:US
Practice Address - Phone:815-991-9053
Practice Address - Fax:815-991-9483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007751101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty