MEDICARE: MAITRI PSYCHOLOGICAL SERVICES, PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1689277576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAITRI PSYCHOLOGICAL SERVICES, PLLC

Provider Business Mailing Address
First Line	:	3320 W FOSTER AVE STE 121
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3320 W FOSTER AVE STE 121
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4813
Country	:	US
Telephone Number	:	630-272-4808
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DIPALI BHARADWAJ
Credential	:	PSYD
Telephone Number	:	630-272-4808

Provider Enumeration Date	:	11/21/2020
Last Update Date	:	11/21/2020

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