Provider Demographics
NPI:1134300718
Name:COHEN, MARVIN RICHARD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:RICHARD
Last Name:COHEN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 LAKE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1046
Mailing Address - Country:US
Mailing Address - Phone:708-386-7974
Mailing Address - Fax:
Practice Address - Street 1:1101 LAKE ST STE 201
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1046
Practice Address - Country:US
Practice Address - Phone:708-386-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILO71003499103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist