Provider Demographics
NPI:1316712656
Name:PROTEAN ARCHETYPES LLC
Entity type:Organization
Organization Name:PROTEAN ARCHETYPES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST/OWNE
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-632-5069
Mailing Address - Street 1:8928 MIDDLETON RD
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:IL
Mailing Address - Zip Code:60561-8441
Mailing Address - Country:US
Mailing Address - Phone:630-632-5069
Mailing Address - Fax:
Practice Address - Street 1:29 S WEBSTER ST STE 290D
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5356
Practice Address - Country:US
Practice Address - Phone:630-632-5069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-16
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty