Provider Demographics
NPI:1861780025
Name:PAUL J. DETAEGE, LCSW, P.C.
Entity type:Organization
Organization Name:PAUL J. DETAEGE, LCSW, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DETAEGE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-988-4965
Mailing Address - Street 1:5215 N RAVENSWOOD AVE
Mailing Address - Street 2:SUITE 314
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1668
Mailing Address - Country:US
Mailing Address - Phone:773-988-4965
Mailing Address - Fax:
Practice Address - Street 1:5215 N RAVENSWOOD AVE
Practice Address - Street 2:SUITE 314
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1668
Practice Address - Country:US
Practice Address - Phone:773-988-4965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149008180251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1598887580OtherTYPE 1 NPI