Provider Demographics
NPI:1831703271
Name:BOULES CLINICAL PSYCHOLOGY GROUP
Entity type:Organization
Organization Name:BOULES CLINICAL PSYCHOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOULES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-321-9809
Mailing Address - Street 1:200 S FRONTAGE RD STE 324
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6953
Mailing Address - Country:US
Mailing Address - Phone:630-321-9809
Mailing Address - Fax:630-537-1550
Practice Address - Street 1:200 S FRONTAGE RD STE 324
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-6953
Practice Address - Country:US
Practice Address - Phone:630-321-9809
Practice Address - Fax:630-537-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-02
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty