MEDICARE: PSYCHOLOGY CENTER P.C.

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	103T00000X	Psychologist	060005211	IL
2	103TC0700X	Clinical Psychologist	071003666	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396735361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGY CENTER P.C.

Provider Business Mailing Address
First Line	:	10713 W DORIC CIRCLE
Second Line	:
City	:	PALOS HILLS
State	:	IL
Zip	:	60465-2220
Country	:	US
Telephone Number	:	773-238-2828
Fax Number	:	708-974-3845

Provider Business Practice Location Address
First Line	:	10343 S WESTERN AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2410
Country	:	US
Telephone Number	:	773-238-2828
Fax Number	:	708-974-3845

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	DR. JAMES T DAVENPORT
Credential	:	PSY D
Telephone Number	:	708-974-4274

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	01/28/2015

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