MEDICARE: DR. RAE WATKINS PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071009266	IL

General Provider Information

NPI Number	:	1003263112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAE WATKINS PSYD

Provider Business Mailing Address
First Line	:	PO BOX 180051
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-0025
Country	:	US
Telephone Number	:	773-600-7580
Fax Number	:

Provider Business Practice Location Address
First Line	:	1519 W IRVING PARK RD STE 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2549
Country	:	US
Telephone Number	:	773-600-7580
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2016
Last Update Date	:	02/28/2023

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