Healthcare Provider Details

I. General information

NPI: 1992728638
Provider Name (Legal Business Name): MOLLY ROMER WITTEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S MICHIGAN AVE SUITE 1301
CHICAGO IL
60603-6191
US

IV. Provider business mailing address

122 S MICHIGAN AVE SUITE 1301
CHICAGO IL
60603-6191
US

V. Phone/Fax

Practice location:
  • Phone: 312-765-0246
  • Fax: 773-493-9104
Mailing address:
  • Phone: 312-765-0246
  • Fax: 773-493-9104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: