MEDICARE: EVIDENCE BASED THERAPY CHICAGO

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

General Provider Information

NPI Number	:	1376376087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVIDENCE BASED THERAPY CHICAGO

Provider Business Mailing Address
First Line	:	5334 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4741
Country	:	US
Telephone Number	:	312-339-1314
Fax Number	:

Provider Business Practice Location Address
First Line	:	445 W ARLINGTON PL APT 1W
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2779
Country	:	US
Telephone Number	:	312-339-1314
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. JESSICA L SCHNEIDER
Credential	:	PSY.D.
Telephone Number	:	312-339-1314

Provider Enumeration Date	:	08/20/2024
Last Update Date	:	08/20/2024

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