Provider Demographics
NPI:1366581829
Name:CENTRUM COUNSELING & PHOBIA CLINIC
Entity type:Organization
Organization Name:CENTRUM COUNSELING & PHOBIA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST PRESIDENT OF CORP
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-386-7974
Mailing Address - Street 1:1101 LAKE ST
Mailing Address - Street 2:#201
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301
Mailing Address - Country:US
Mailing Address - Phone:708-386-7974
Mailing Address - Fax:708-386-7977
Practice Address - Street 1:1101 LAKE ST
Practice Address - Street 2:#201
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301
Practice Address - Country:US
Practice Address - Phone:708-386-7974
Practice Address - Fax:708-386-7977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILI1071003499103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
210262Medicare ID - Type Unspecified
K12028Medicare ID - Type Unspecified