Healthcare Provider Details

I. General information

NPI: 1083912034
Provider Name (Legal Business Name): JEFFRY WAYNE STINE PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JEFFRY STINE

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 SKOKIE BLVD STE 115
NORTHBROOK IL
60062
US

IV. Provider business mailing address

2450 W ADDISON ST APT 2A
CHICAGO IL
60618-5960
US

V. Phone/Fax

Practice location:
  • Phone: 224-388-3633
  • Fax: 847-929-4513
Mailing address:
  • Phone: 224-388-3633
  • Fax: 847-929-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008039
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number071008039
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: