Provider Demographics
NPI:1497866354
Name:MORETTI, ROBERT J (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:MORETTI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 E LAKE ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-5921
Mailing Address - Country:US
Mailing Address - Phone:312-884-8317
Mailing Address - Fax:312-884-8317
Practice Address - Street 1:63 E LAKE ST
Practice Address - Street 2:SUITE 404
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5921
Practice Address - Country:US
Practice Address - Phone:312-884-8317
Practice Address - Fax:312-884-8317
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
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
IL016-72887Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST