Provider Demographics
NPI:1497137046
Name:WAX, KATHRYN J (PSYD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:J
Last Name:WAX
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 1:644 W WEBSTER AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3710
Mailing Address - Country:US
Mailing Address - Phone:773-991-3016
Mailing Address - Fax:
Practice Address - Street 1:644 W WEBSTER AVE UNIT B
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3710
Practice Address - Country:US
Practice Address - Phone:773-991-3016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008160103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical