Organization
CRAWFORD AVENUE GROUP INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KELLI KLINGER (PRESIDENT)
(847) 875-4411
Entity
Organization
Contact information
Practice address
2530 CRAWFORD AVE STE 206, EVANSTON, IL 60201-4959
(847) 875-4411
Mailing address
2530 CRAWFORD AVE STE 206, EVANSTON, IL 60201-4959
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
071007124
IL
1041C0700X
Clinical Social Worker
149003065
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000603083
BLUE CROSS BLUE SHIELD OF ILLINOIS
IL
01
—
1619019080
TYPE 1-NPI
IL
01
—
1891819363
TYPE 1-NPI
IL
Enumeration date
06/02/2018
Last updated
06/02/2018
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