Healthcare Provider Details

I. General information

NPI: 1902203631
Provider Name (Legal Business Name): TIFFANY L KELLER PSYD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N. MICHIGAN 1124
CHICAGO IL
60602
US

IV. Provider business mailing address

2310 N. MONTICELLO AVE
CHICAGO IL
60647
US

V. Phone/Fax

Practice location:
  • Phone: 773-931-6430
  • Fax:
Mailing address:
  • Phone: 773-931-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number071007170
License Number StateIL

VIII. Authorized Official

Name: DR. TIFFANY L KELLER
Title or Position: PSYCHOLOGIST
Credential: PSY.D.
Phone: 773-931-6430