Provider Demographics
NPI:1558148460
Name:TRAUMA THERAPY CHICAGO LLC
Entity type:Organization
Organization Name:TRAUMA THERAPY CHICAGO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KEIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:IZUMI
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:805-300-4056
Mailing Address - Street 1:1730 N CLARK ST APT 1410
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5857
Mailing Address - Country:US
Mailing Address - Phone:805-300-4056
Mailing Address - Fax:
Practice Address - Street 1:1730 N CLARK ST APT 1410
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5857
Practice Address - Country:US
Practice Address - Phone:805-300-4056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health