MEDICARE: BRETT FRY, PSY.D., P.C.

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	071006942	IL

General Provider Information

NPI Number	:	1306116074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRETT FRY, PSY.D., P.C.

Provider Business Mailing Address
First Line	:	405 N WABASH AVE
Second Line	:	SUITE 1815
City	:	CHICAGO
State	:	IL
Zip	:	60611-5661
Country	:	US
Telephone Number	:	773-573-3612
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 N WABASH AVE
Second Line	:	SUITE 1815
City	:	CHICAGO
State	:	IL
Zip	:	60611-5661
Country	:	US
Telephone Number	:	773-573-3612
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRETT FRY
Credential	:	PSY.D.
Telephone Number	:	773-573-3612

Provider Enumeration Date	:	01/11/2012
Last Update Date	:	01/11/2012

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