Organization
POWER TEEN PROGRAM
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. GLENDA CUNNINGHAM (CHIEF EXECUTIVE OFFICER)
(312) 521-3336
Entity
Organization
Contact information
Practice address
300 N CENTRAL AVE, CHICAGO, IL 60644
(312) 261-1421
Mailing address
9336 MORGAN AVE, EVANSTON, IL 60203-1418
(312) 261-1421
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
071002911
IL
Other
Enumeration date
12/16/2009
Last updated
12/16/2009
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