MEDICARE: OCD TREATMENT CENTER, LLC

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	071.006130	IL

General Provider Information

NPI Number	:	1679711642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCD TREATMENT CENTER, LLC

Provider Business Mailing Address
First Line	:	1130 W CORNELIA AVE APT D
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1549
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 W CORNELIA AVE APT D
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-1549
Country	:	US
Telephone Number	:	773-220-1995
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	KEVIN L GYOERKOE
Credential	:	PSY.D.
Telephone Number	:	773-220-1995

Provider Enumeration Date	:	01/29/2009
Last Update Date	:	01/29/2009

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