Healthcare Provider Details

I. General information

NPI: 1932441631
Provider Name (Legal Business Name): ILLIANA PSYCHIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 E COLUMBUS DR
EAST CHICAGO IN
46312-2830
US

IV. Provider business mailing address

4320 FIR ST SUITE 307
EAST CHICAGO IN
46312-3052
US

V. Phone/Fax

Practice location:
  • Phone: 219-397-6369
  • Fax:
Mailing address:
  • Phone: 219-455-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number1038685
License Number StateIN

VIII. Authorized Official

Name: DR. FARZANA A KHAN
Title or Position: CEO
Credential: MD
Phone: 219-397-6369