Provider Demographics
NPI:1457499188
Name:BUHAI-JACOBUS, LIZ (PSYD)
Entity Type:Individual
Prefix:
First Name:LIZ
Middle Name:
Last Name:BUHAI-JACOBUS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2244
Mailing Address - Country:US
Mailing Address - Phone:708-574-5876
Mailing Address - Fax:
Practice Address - Street 1:533 W NORTH AVE
Practice Address - Street 2:#206
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2135
Practice Address - Country:US
Practice Address - Phone:708-574-5876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL200768Medicare ID - Type Unspecified