Provider Demographics
NPI:1720812860
Name:ALZA GREAT LAKES PSYCHOTHERAPY PROFESSIONAL LLC
Entity type:Organization
Organization Name:ALZA GREAT LAKES PSYCHOTHERAPY PROFESSIONAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:ENA
Authorized Official - Middle Name:ISIS
Authorized Official - Last Name:MILLLWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-707-6093
Mailing Address - Street 1:7061 NORTH AVE # 292
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1015
Mailing Address - Country:US
Mailing Address - Phone:708-824-7533
Mailing Address - Fax:
Practice Address - Street 1:1719 N RUTHERFORD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-3942
Practice Address - Country:US
Practice Address - Phone:708-824-7533
Practice Address - Fax:312-748-4256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-30
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty