MEDICARE: DR. TONYA MARIE MESTEMAKER 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04932470	OTHER	IL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1659460715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TONYA MARIE MESTEMAKER PSY.D.

Provider Business Mailing Address
First Line	:	4443 N ALBANY AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4501
Country	:	US
Telephone Number	:	773-383-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 N SHORE DR
Second Line	:	SUITE 174
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-2243
Country	:	US
Telephone Number	:	773-383-7700
Fax Number	:	847-615-1697

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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