Provider Demographics
NPI:1285384248
Name:TABULARASA INTEGRATIVE HEALTH INC
Entity type:Organization
Organization Name:TABULARASA INTEGRATIVE HEALTH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, CADC, CCTP-II
Authorized Official - Phone:224-430-8109
Mailing Address - Street 1:135 N GREENLEAF ST STE 120
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3334
Mailing Address - Country:US
Mailing Address - Phone:224-285-0728
Mailing Address - Fax:224-249-4411
Practice Address - Street 1:135 N GREENLEAF ST STE 120
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3334
Practice Address - Country:US
Practice Address - Phone:224-430-8109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-24
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1285384248Medicaid
IL342760608001Medicaid