=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457689085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PROF. ELIZABETH ROTTENBERG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2009
-----------------------------------------------------
Last Update Date | 11/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2352 N CLIFTON AVE SUITE 150.17
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-325-4864
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1218 W JARVIS AVE APT 2S
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-203-4058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------