MEDICARE: PAVANAM SASHA VALUYEETHAM PSYD

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	071.011192	IL
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1508598756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAVANAM SASHA VALUYEETHAM PSYD

Provider Business Mailing Address
First Line	:	3925 N LINCOLN AVE APT 2B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2428
Country	:	US
Telephone Number	:	312-520-2946
Fax Number	:

Provider Business Practice Location Address
First Line	:	2419 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-2020
Country	:	US
Telephone Number	:	773-755-1775
Fax Number	:

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

Provider Enumeration Date	:	06/27/2022
Last Update Date	:	05/21/2024

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