Healthcare Provider Details

I. General information

NPI: 1306339478
Provider Name (Legal Business Name): ISAIAH SYPHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W LUNT AVE APT 3A
CHICAGO IL
60626-3047
US

IV. Provider business mailing address

1215 W LUNT AVE APT 3A
CHICAGO IL
60626-3047
US

V. Phone/Fax

Practice location:
  • Phone: 313-520-8232
  • Fax:
Mailing address:
  • Phone: 313-520-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301017424
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: