Provider Demographics
NPI:1922188929
Name:ABBOTT, KATHY DANA (PSYD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:DANA
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MRS
Other - First Name:KATHY
Other - Middle Name:DANA
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4342 S TRUMBALL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632
Mailing Address - Country:US
Mailing Address - Phone:773-807-0936
Mailing Address - Fax:773-247-0507
Practice Address - Street 1:3317 W 95TH ST
Practice Address - Street 2:STE 205
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805
Practice Address - Country:US
Practice Address - Phone:773-807-0936
Practice Address - Fax:773-247-0507
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006594103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208281Medicare PIN