Individual
THIDAPORN IAMSUTTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
QMHP
Contact information
Practice address
4753 N BROADWAY ST STE 700, CHICAGO, IL 60640-4995
(773) 293-8430
(773) 728-4751
Mailing address
4753 N BROADWAY ST STE 700, CHICAGO, IL 60640-4995
(773) 293-8430
(773) 728-4751
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Enumeration date
01/26/2018
Last updated
01/26/2018
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