MEDICARE: DR. PAULA T DICANIO PHD.

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		IL

General Provider Information

NPI Number	:	1952524019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAULA T DICANIO PHD.

Provider Business Mailing Address
First Line	:	2213 LAKESIDE DR
Second Line	:
City	:	BANNOCKBURN
State	:	IL
Zip	:	60015-1265
Country	:	US
Telephone Number	:	847-604-9441
Fax Number	:	847-604-9445

Provider Business Practice Location Address
First Line	:	2213 LAKESIDE DR
Second Line	:
City	:	BANNOCKBURN
State	:	IL
Zip	:	60015-1265
Country	:	US
Telephone Number	:	847-604-9441
Fax Number	:	847-604-9445

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	04/03/2021

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