Healthcare Provider Details

I. General information

NPI: 1073684643
Provider Name (Legal Business Name): DAVID CHARLES USNDEK PSYD LC PC CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6031 N MARMORA AVE
CHICAGO IL
60646-3903
US

IV. Provider business mailing address

6031 N MARMORA AVE
CHICAGO IL
60646-3903
US

V. Phone/Fax

Practice location:
  • Phone: 773-450-8049
  • Fax:
Mailing address:
  • Phone: 773-450-8049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4703
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071007224
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: