MEDICARE: GRACE AHN-IM 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	390200000X	Student in an Organized Health Care Education/Training Program
2	103TC0700X	Clinical Psychologist	071010384	IL

General Provider Information

NPI Number	:	1578016937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE AHN-IM PSYD

Provider Business Mailing Address
First Line	:	1111 N WELLS ST STE 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-7632
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 N WELLS ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-7635
Country	:	US
Telephone Number	:	312-573-8860
Fax Number	:

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

Provider Enumeration Date	:	08/02/2016
Last Update Date	:	02/18/2025

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