Healthcare Provider Details

I. General information

NPI: 1265662639
Provider Name (Legal Business Name): AHMAD REZA DJANGI PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5090 W HARRISON ST
CHICAGO IL
60644-5141
US

IV. Provider business mailing address

5090 W HARRISON ST
CHICAGO IL
60644-5141
US

V. Phone/Fax

Practice location:
  • Phone: 773-722-7900
  • Fax:
Mailing address:
  • Phone: 773-722-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180-004505
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: