MEDICARE: DR. RAY EDWARD QUACKENBUSH PSY.D.

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

General Provider Information

NPI Number	:	1619970357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAY EDWARD QUACKENBUSH PSY.D.

Provider Business Mailing Address
First Line	:	4801 W PETERSON AVE
Second Line	:	STE 525
City	:	CHICAGO
State	:	IL
Zip	:	60646-5731
Country	:	US
Telephone Number	:	773-286-3100
Fax Number	:	773-777-7543

Provider Business Practice Location Address
First Line	:	4801 W PETERSON AVE
Second Line	:	STE 525
City	:	CHICAGO
State	:	IL
Zip	:	60646-5731
Country	:	US
Telephone Number	:	773-286-3100
Fax Number	:	773-777-7543

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

Provider Enumeration Date	:	05/26/2005
Last Update Date	:	07/08/2007

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