Healthcare Provider Details

I. General information

NPI: 1770903353
Provider Name (Legal Business Name): TAMAR D GEFEN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

676 N SAINT CLAIR ST
CHICAGO IL
60611-2927
US

IV. Provider business mailing address

320 E SUPERIOR ST SEARLE, 11
CHICAGO IL
60611-3010
US

V. Phone/Fax

Practice location:
  • Phone: 312-908-9339
  • Fax:
Mailing address:
  • Phone: 312-503-5206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009672
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: