Provider Demographics
NPI:1558626267
Name:BRIETZKE, COLIN A (PSY D)
Entity Type:Individual
Prefix:DR
First Name:COLIN
Middle Name:A
Last Name:BRIETZKE
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 N GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1552
Mailing Address - Country:US
Mailing Address - Phone:773-931-3439
Mailing Address - Fax:
Practice Address - Street 1:101 N MARION ST
Practice Address - Street 2:STE 313
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1023
Practice Address - Country:US
Practice Address - Phone:773-931-3439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008376103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist