Healthcare Provider Details

I. General information

NPI: 1639798598
Provider Name (Legal Business Name): BRETT L OPELT PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date: 07/11/2022
Reactivation Date: 04/22/2024

III. Provider practice location address

1241 W JACKSON BLVD UNIT 310
CHICAGO IL
60607-2858
US

IV. Provider business mailing address

1241 W JACKSON BLVD UNIT 310
CHICAGO IL
60607-2858
US

V. Phone/Fax

Practice location:
  • Phone: 414-416-5732
  • Fax:
Mailing address:
  • Phone: 414-416-5732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6477-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071022563
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number07641
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: