Provider Demographics
NPI:1639235997
Name:TANNEN, DEIRDRE L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DEIRDRE
Middle Name:L
Last Name:TANNEN
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 1:5327 N SHERIDAN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2774
Mailing Address - Country:US
Mailing Address - Phone:773-989-1111
Mailing Address - Fax:773-989-2782
Practice Address - Street 1:5327 N SHERIDAN RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2774
Practice Address - Country:US
Practice Address - Phone:773-989-1111
Practice Address - Fax:773-989-2782
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X, 103TR0400X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
203269Medicare ID - Type Unspecified