MEDICARE: THIRD COAST PSYCHOLOGICAL SERVICES, PLLC

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

General Provider Information

NPI Number	:	1417739186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THIRD COAST PSYCHOLOGICAL SERVICES, PLLC

Provider Business Mailing Address
First Line	:	1913 W 19TH ST APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-7115
Country	:	US
Telephone Number	:	231-534-4341
Fax Number	:

Provider Business Practice Location Address
First Line	:	1913 W 19TH ST APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-7115
Country	:	US
Telephone Number	:	231-534-4341
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICAL DIRECTOR
Name	:	DR. AMY J EIERMANN
Credential	:	PH.D.
Telephone Number	:	231-534-4341

Provider Enumeration Date	:	10/17/2023
Last Update Date	:	10/17/2023

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