=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700493848
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AILA M AMIL PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2020
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2502 N CLARK ST # 212
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60614-1850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-930-9553
-----------------------------------------------------
Fax | 773-688-2637
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7410264
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60674-0264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-942-6323
-----------------------------------------------------
Fax | 779-210-5541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3855-57
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071010409
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------