Provider Demographics
NPI:1437424140
Name:LAUDERMITH, ARIEL LYNN (PHD)
Entity Type:Individual
Prefix:
First Name:ARIEL
Middle Name:LYNN
Last Name:LAUDERMITH
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 1:1235 S PRAIRIE AVE
Mailing Address - Street 2:APT 3008
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3403
Mailing Address - Country:US
Mailing Address - Phone:708-202-8387
Mailing Address - Fax:
Practice Address - Street 1:5000 S 5TH AVE
Practice Address - Street 2:116B
Practice Address - City:HINES
Practice Address - State:IL
Practice Address - Zip Code:60141-3030
Practice Address - Country:US
Practice Address - Phone:708-202-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008299103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical