MEDICARE: DR. ELLYN K. DANIELS 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	071005777	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01632252	OTHER	IL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1952524183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLYN K. DANIELS PH.D.

Provider Business Mailing Address
First Line	:	150 N MICHIGAN AVE
Second Line	:	SUITE 2145
City	:	CHICAGO
State	:	IL
Zip	:	60601-7553
Country	:	US
Telephone Number	:	312-944-9950
Fax Number	:	312-726-8200

Provider Business Practice Location Address
First Line	:	150 N MICHIGAN AVE
Second Line	:	SUITE 2145
City	:	CHICAGO
State	:	IL
Zip	:	60601-7553
Country	:	US
Telephone Number	:	312-944-9950
Fax Number	:	312-726-8200

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	06/18/2010

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