Provider Demographics
NPI:1639542368
Name:MEDVEDEVA, SVETLANA (PSYD/HSPP)
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:MEDVEDEVA
Suffix:
Gender:F
Credentials:PSYD/HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6385
Mailing Address - Country:US
Mailing Address - Phone:219-757-1928
Mailing Address - Fax:219-757-1950
Practice Address - Street 1:5900 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2423
Practice Address - Country:US
Practice Address - Phone:219-931-0427
Practice Address - Fax:219-937-5808
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178007918101YP2500X
IN20042903A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional