MEDICARE: DR. DAVID S. DEBOER PH.D.

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		IL

General Provider Information

NPI Number	:	1942373238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID S. DEBOER PH.D.

Provider Business Mailing Address
First Line	:	2242 W LELAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-2006
Country	:	US
Telephone Number	:	312-409-9662
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 N MICHIGAN AVE STE 540
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-7426
Country	:	US
Telephone Number	:	312-409-9662
Fax Number	:

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/08/2007

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