Healthcare Provider Details

I. General information

NPI: 1275667032
Provider Name (Legal Business Name): LORI NINETTE OSBORNE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 N WILTON AVE FL 2 ADVOCATE IL MASONIC PEDIATRIC DEVELOPMENTAL CENTER
CHICAGO IL
60657-4424
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 773-296-7688
  • Fax: 773-296-7281
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.006934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: