Healthcare Provider Details

I. General information

NPI: 1104854892
Provider Name (Legal Business Name): TONY A FLETCHER PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E OHIO ST SUITE 450
CHICAGO IL
60611-3302
US

IV. Provider business mailing address

1205 LINDEN AVE
OAK PARK IL
60302-1244
US

V. Phone/Fax

Practice location:
  • Phone: 312-961-9974
  • Fax:
Mailing address:
  • Phone: 312-961-9974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-005279
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071-005279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: