MEDICARE: DR. LORRAINE D D'ASTA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	71-2763	IL
2	103TS0200X	School Psychologist	1163916	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	227-2056	OTHER	IL	BCBS PROVIDER ID

General Provider Information

NPI Number	:	1194815944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORRAINE D D'ASTA PH.D.

Provider Business Mailing Address
First Line	:	115 S EDGEWOOD AVE
Second Line	:
City	:	LA GRANGE
State	:	IL
Zip	:	60525-2149
Country	:	US
Telephone Number	:	630-655-9040
Fax Number	:	708-482-0667

Provider Business Practice Location Address
First Line	:	111 W CHICAGO AVE
Second Line	:
City	:	HINSDALE
State	:	IL
Zip	:	60521-3356
Country	:	US
Telephone Number	:	630-655-9040
Fax Number	:	708-482-0667

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	09/11/2025

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