MEDICARE: DR. KAREN LISA MADDI PH.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	71004057	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001673361	OTHER	IL	BCBS PROVIDER

General Provider Information

NPI Number	:	1679617864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAREN LISA MADDI PH.D.

Provider Business Mailing Address
First Line	:	2235 W FLETCHER ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-6403
Country	:	US
Telephone Number	:	773-248-8588
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 S LA SALLE ST
Second Line	:	SUITE 2600
City	:	CHICAGO
State	:	IL
Zip	:	60603-1203
Country	:	US
Telephone Number	:	312-458-0873
Fax Number	:

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

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/08/2007

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