Healthcare Provider Details

I. General information

NPI: 1679617864
Provider Name (Legal Business Name): KAREN LISA MADDI PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S LA SALLE ST SUITE 2600
CHICAGO IL
60603-1203
US

IV. Provider business mailing address

2235 W FLETCHER ST
CHICAGO IL
60618-6403
US

V. Phone/Fax

Practice location:
  • Phone: 312-458-0873
  • Fax:
Mailing address:
  • Phone: 773-248-8588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number71004057
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: