Provider Demographics
NPI:1629047469
Name:KOSTAS, KONSTANTINOS D (PHD)
Entity Type:Individual
Prefix:
First Name:KONSTANTINOS
Middle Name:D
Last Name:KOSTAS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:DINO
Other - Middle Name:
Other - Last Name:KOSTAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4501 N WINCHESTER AVE
Mailing Address - Street 2:3RD FL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640
Mailing Address - Country:US
Mailing Address - Phone:773-250-0500
Mailing Address - Fax:773-250-0497
Practice Address - Street 1:4501 N WINCHESTER AVE
Practice Address - Street 2:2ND FL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:773-250-0500
Practice Address - Fax:773-250-0497
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005172103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK27992Medicare PIN
S49783Medicare UPIN
ILK27991Medicare PIN