MEDICARE: MR. NATHANIEL GOLDBLATT 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	103T00000X	Psychologist	071007696	IL

General Provider Information

NPI Number	:	1861720971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NATHANIEL GOLDBLATT PSYD

Provider Business Mailing Address
First Line	:	1942 W RACE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-6248
Country	:	US
Telephone Number	:	773-880-2400
Fax Number	:	773-880-2402

Provider Business Practice Location Address
First Line	:	2835 N SHEFFIELD AVE STE 204
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-5083
Country	:	US
Telephone Number	:	312-863-9549
Fax Number	:

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

Provider Enumeration Date	:	12/01/2009
Last Update Date	:	12/10/2009

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