MEDICARE: CHRISTY QUEROL 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	071010556	IL

General Provider Information

NPI Number	:	1588338461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTY QUEROL PSYD

Provider Business Mailing Address
First Line	:	3432 W DIVERSEY AVE FL 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1221
Country	:	US
Telephone Number	:	786-325-3006
Fax Number	:

Provider Business Practice Location Address
First Line	:	3432 W DIVERSEY AVE FL 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1221
Country	:	US
Telephone Number	:	312-380-1747
Fax Number	:

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

Provider Enumeration Date	:	08/04/2021
Last Update Date	:	08/04/2021

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Directions to “ CHRISTY QUEROL PSYD” Practice Location

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