Provider Demographics
NPI:1700053360
Name:BJORGE, KEITH V (PSY D)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:V
Last Name:BJORGE
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 1:61 S OLD RAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-3127
Mailing Address - Country:US
Mailing Address - Phone:847-438-4222
Mailing Address - Fax:
Practice Address - Street 1:61 S OLD RAND RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-3127
Practice Address - Country:US
Practice Address - Phone:847-438-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005483103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical