Provider Demographics
NPI:1376831172
Name:PORTSCHE, ROBERT J JR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:PORTSCHE
Suffix:JR
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 1:1735 N ASHLAND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1435
Mailing Address - Country:US
Mailing Address - Phone:312-519-8314
Mailing Address - Fax:
Practice Address - Street 1:1735 N ASHLAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1435
Practice Address - Country:US
Practice Address - Phone:312-519-8314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical