Provider Demographics
NPI:1710676549
Name:MACAPAGAL FRIDBERG, KATHRYN ROSE OLAY (PHD)
Entity Type:Individual
Prefix:
First Name:KATHRYN ROSE
Middle Name:OLAY
Last Name:MACAPAGAL FRIDBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:MACAPAGAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:625 N MICHIGAN AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2835 N SHEFFIELD AVE STE 209
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5083
Practice Address - Country:US
Practice Address - Phone:312-834-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042778A103TC0700X
IL071009198103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical