Provider Demographics
NPI:1114902962
Name:NATVIG, CONNIE BEA (PHD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:BEA
Last Name:NATVIG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9611 165TH ST
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5654
Mailing Address - Country:US
Mailing Address - Phone:708-955-4950
Mailing Address - Fax:708-310-3486
Practice Address - Street 1:9611 165TH ST STE 15
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467
Practice Address - Country:US
Practice Address - Phone:708-955-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004997103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S09606Medicare UPIN
369430Medicare ID - Type Unspecified