Provider Demographics
NPI:1942913280
Name:FANDOM BEHAVIORAL HEALTH CLINIC PLLC
Entity type:Organization
Organization Name:FANDOM BEHAVIORAL HEALTH CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA, LCPC
Authorized Official - Phone:803-719-3237
Mailing Address - Street 1:564 W RANDOLPH ST UNIT 820
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-2218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:564 W RANDOLPH ST UNIT 820
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-2218
Practice Address - Country:US
Practice Address - Phone:708-789-5669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-02
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180013605Medicaid
IL180013884Medicaid