Provider Demographics
NPI:1710425319
Name:LODRO, TAK-SENG (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TAK-SENG
Middle Name:
Last Name:LODRO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 RIDGE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5908
Mailing Address - Country:US
Mailing Address - Phone:312-690-3719
Mailing Address - Fax:
Practice Address - Street 1:1740 RIDGE AVE STE 101
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5908
Practice Address - Country:US
Practice Address - Phone:312-690-3719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009462103TC0700X, 103TC2200X, 103TF0000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily