Healthcare Provider Details

I. General information

NPI: 1639542368
Provider Name (Legal Business Name): SVETLANA MEDVEDEVA PSYD/HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 11/02/2024
Certification Date: 11/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 W SURF ST STE 809
CHICAGO IL
60657-7227
US

IV. Provider business mailing address

8400 LOUISIANA ST
MERRILLVILLE IN
46410-6385
US

V. Phone/Fax

Practice location:
  • Phone: 630-428-7890
  • Fax:
Mailing address:
  • Phone: 219-757-1928
  • Fax: 219-757-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071009391
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178007918
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: