MEDICARE: LORI G TALL PSYD

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	103G00000X	Clinical Neuropsychologist	53521462501	UT

General Provider Information

NPI Number	:	1750308524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI G TALL PSYD

Provider Business Mailing Address
First Line	:	8 S MICHIGAN AVE
Second Line	:	SET 500
City	:	CHICAGO
State	:	IL
Zip	:	60603-3357
Country	:	US
Telephone Number	:	312-609-5404
Fax Number	:

Provider Business Practice Location Address
First Line	:	8 S MICHIGAN AVE
Second Line	:	SET 500
City	:	CHICAGO
State	:	IL
Zip	:	60603-3357
Country	:	US
Telephone Number	:	312-609-5404
Fax Number	:

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

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	01/11/2021

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