MEDICARE: JOAN SOPHIE & DEBORAH SCOTT

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		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01619507	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1578641163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOAN SOPHIE & DEBORAH SCOTT

Provider Business Mailing Address
First Line	:	3047 N LINCOLN AVE
Second Line	:	SUITE 400
City	:	CHICAGO
State	:	IL
Zip	:	60657-4999
Country	:	US
Telephone Number	:	773-472-7646
Fax Number	:

Provider Business Practice Location Address
First Line	:	3047 N LINCOLN AVE
Second Line	:	SUITE 400
City	:	CHICAGO
State	:	IL
Zip	:	60657-4999
Country	:	US
Telephone Number	:	773-472-7646
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. DEBORAH SCOTT
Credential	:	PHD
Telephone Number	:	773-472-7646

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	08/22/2020

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