Organization
PAUL J. DETAEGE, LCSW, P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PAUL J DETAEGE LCSW (PRESIDENT)
(773) 988-4965
Entity
Organization
Contact information
Practice address
5215 N RAVENSWOOD AVE, SUITE 314, CHICAGO, IL 60640-1668
(773) 988-4965
Mailing address
5215 N RAVENSWOOD AVE, SUITE 314, CHICAGO, IL 60640-1668
(773) 988-4965
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
149008180
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1598887580
TYPE 1 NPI
IL
Enumeration date
07/20/2011
Last updated
07/20/2011
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