MEDICARE: DR. TEVYN P ANDERSON 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	071.008785	IL

General Provider Information

NPI Number	:	1285022251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TEVYN P ANDERSON PSYD

Provider Business Mailing Address
First Line	:	5042 N GLENWOOD AVE
Second Line	:	APT. 2W
City	:	CHICAGO
State	:	IL
Zip	:	60640-2870
Country	:	US
Telephone Number	:	847-769-1873
Fax Number	:

Provider Business Practice Location Address
First Line	:	5042 N GLENWOOD AVE
Second Line	:	APT. 2W
City	:	CHICAGO
State	:	IL
Zip	:	60640-2870
Country	:	US
Telephone Number	:	847-769-1873
Fax Number	:

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

Provider Enumeration Date	:	12/29/2014
Last Update Date	:	12/29/2014

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