Provider Demographics
NPI:1154187433
Name:INTEGRATIVE PRIMARY CARE AND MENTAL HEALTH CLINIC, LLC
Entity type:Organization
Organization Name:INTEGRATIVE PRIMARY CARE AND MENTAL HEALTH CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC, PMHNP-B
Authorized Official - Phone:312-975-8268
Mailing Address - Street 1:3201 S WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3501
Mailing Address - Country:US
Mailing Address - Phone:312-975-8268
Mailing Address - Fax:
Practice Address - Street 1:3201 S WALLACE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3501
Practice Address - Country:US
Practice Address - Phone:312-975-8268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-26
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1154187433OtherGROUP NPI
IL1497299689OtherINDIVIDUAL NPI