MEDICARE: ANDERSONVILLE PSYCHOLOGY, PC

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	071.009490	IL

General Provider Information

NPI Number	:	1962924829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDERSONVILLE PSYCHOLOGY, PC

Provider Business Mailing Address
First Line	:	1641 W FARWELL AVE APT NB
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-6064
Country	:	US
Telephone Number	:	773-985-8746
Fax Number	:

Provider Business Practice Location Address
First Line	:	5412 N CLARK ST STE 220
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-1272
Country	:	US
Telephone Number	:	773-985-8746
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JONATHAN SMITH
Credential	:	PSYD
Telephone Number	:	773-985-8746

Provider Enumeration Date	:	07/12/2017
Last Update Date	:	07/12/2017

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