Provider Demographics
NPI:1104336114
Name:BIRCHWOOD CLINIC, LLC
Entity type:Organization
Organization Name:BIRCHWOOD CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BUSH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:312-806-2140
Mailing Address - Street 1:2302 W NORTH AVE STE 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-9755
Mailing Address - Country:US
Mailing Address - Phone:312-806-2140
Mailing Address - Fax:
Practice Address - Street 1:2302 W NORTH AVE STE 1E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-9755
Practice Address - Country:US
Practice Address - Phone:312-806-2140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009612103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty