Provider Demographics
NPI:1669455408
Name:ANDRISE, PATRICIA JEWELL (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JEWELL
Last Name:ANDRISE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 CHESTNUT
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521
Mailing Address - Country:US
Mailing Address - Phone:630-850-9650
Mailing Address - Fax:630-850-9607
Practice Address - Street 1:333 CHESTNUT ST
Practice Address - Street 2:SUITE 206
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3247
Practice Address - Country:US
Practice Address - Phone:630-850-9650
Practice Address - Fax:630-850-9607
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2205358OtherBCBS
D20860Medicare UPIN
IL2205358OtherBCBS