Provider Demographics
NPI:1154440519
Name:DEJOSEPH, ANTHONY M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:M
Last Name:DEJOSEPH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:ASSOCIATES IN
Other - Middle Name:BEHAVIORAL
Other - Last Name:SCIENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYCHOLOGIST
Mailing Address - Street 1:6201 CERMAK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-5743
Mailing Address - Country:US
Mailing Address - Phone:708-214-7172
Mailing Address - Fax:708-366-5556
Practice Address - Street 1:6201 CERMAK RD STE 2
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-5743
Practice Address - Country:US
Practice Address - Phone:708-214-7172
Practice Address - Fax:708-366-5556
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003731103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL924490Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL904131Medicare ID - Type UnspecifiedMEDICARE NUMBER