Healthcare Provider Details

I. General information

NPI: 1083168041
Provider Name (Legal Business Name): TETYANA KOSTYSHYNA PSYD, LCPC, LSOE/TP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S RANDALL RD STE 204
ST CHARLES IL
60174-5918
US

IV. Provider business mailing address

555 S RANDALL RD STE 204
ST CHARLES IL
60174-5918
US

V. Phone/Fax

Practice location:
  • Phone: 312-818-9300
  • Fax: 888-488-2604
Mailing address:
  • Phone: 312-818-9300
  • Fax: 888-488-2604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3415 - 57
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180009177
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009432
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: