MEDICARE: DOUGLAS CULBERT, PHD

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	071004224	IL

General Provider Information

NPI Number	:	1568964575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS CULBERT, PHD

Provider Business Mailing Address
First Line	:	1220 W GLENLAKE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-2504
Country	:	US
Telephone Number	:	773-844-6576
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 N MICHIGAN AVE STE 2401
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-7451
Country	:	US
Telephone Number	:	312-467-1519
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DR. DOUGLAS S CULBERT
Credential	:	PHD
Telephone Number	:	312-467-1519

Provider Enumeration Date	:	03/06/2018
Last Update Date	:	03/06/2018

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