MEDICARE: KEENAN FERRELL 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	00987	IA
2	103TC0700X	Clinical Psychologist	20041967A	IN
3	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1801927702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEENAN FERRELL PSY.D.

Provider Business Mailing Address
First Line	:	5455 N SHERIDAN RD
Second Line	:	1709
City	:	CHICAGO
State	:	IL
Zip	:	60640-1958
Country	:	US
Telephone Number	:	773-944-5301
Fax Number	:	773-944-5302

Provider Business Practice Location Address
First Line	:	5455 N SHERIDAN RD
Second Line	:	1709
City	:	CHICAGO
State	:	IL
Zip	:	60640-1958
Country	:	US
Telephone Number	:	773-944-5301
Fax Number	:	773-944-5302

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

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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