=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245499979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHICAGO NORTHSHORE PSYCHOLOGISTS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2008
-----------------------------------------------------
Last Update Date | 06/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4905 OLD ORCHARD CTR SUITE 607
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-259-7732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4905 OLD ORCHARD CTR SUITE 607
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-259-7732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | DR. CATHERINE A KIEFT
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 773-259-7732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 071007068
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071006758
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------