Provider Demographics
NPI:1740786441
Name:JUSTICE, AMELIA L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:L
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3047 W WILSON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4331
Mailing Address - Country:US
Mailing Address - Phone:815-995-7028
Mailing Address - Fax:
Practice Address - Street 1:4256 N RAVENSWOOD AVE STE 220
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1114
Practice Address - Country:US
Practice Address - Phone:815-995-7028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009743103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical