=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073169892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLIVIA CHAVEZ, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2019
-----------------------------------------------------
Last Update Date | 12/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2650 W MONTROSE AVE STE 307
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-1561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-217-0277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4239 W WRIGHTWOOD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60639-2059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | OLIVIA CHAVEZ
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 773-217-0277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------