Provider Demographics
NPI:1194272211
Name:LARUE, DAMITA SUNWOLF (PSYD, FT, CCISM)
Entity type:Individual
Prefix:DR
First Name:DAMITA
Middle Name:SUNWOLF
Last Name:LARUE
Suffix:
Gender:F
Credentials:PSYD, FT, CCISM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5547 N RAVENSWOOD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1125
Mailing Address - Country:US
Mailing Address - Phone:773-609-2069
Mailing Address - Fax:
Practice Address - Street 1:5547 N RAVENSWOOD AVE STE 103
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1125
Practice Address - Country:US
Practice Address - Phone:773-609-2069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3563-57103TC0700X
IN20043101A103TC0700X
AK114769103TC0700X
IL071.009773103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical