Healthcare Provider Details

I. General information

NPI: 1356922561
Provider Name (Legal Business Name): MICHAEL CHAMBERLAIN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W SUNNYSIDE AVE STE 100
CHICAGO IL
60640-5684
US

IV. Provider business mailing address

6851 S EVANS AVE
CHICAGO IL
60637-4118
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax: 773-388-8936
Mailing address:
  • Phone: 503-312-1635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071010508
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: