Healthcare Provider Details

I. General information

NPI: 1578209656
Provider Name (Legal Business Name): JOHN PATRICK BRADY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK BRADY PHD

II. Dates (important events)

Enumeration Date: 05/11/2022
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W SUPERIOR ST
CHICAGO IL
60654-3548
US

IV. Provider business mailing address

1727 W SUPERIOR ST # 2F
CHICAGO IL
60622-5646
US

V. Phone/Fax

Practice location:
  • Phone: 312-508-3645
  • Fax:
Mailing address:
  • Phone: 312-508-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.022411
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: