Provider Demographics
NPI:1295717577
Name:TELLERMAN, JUDITH S (PHD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:S
Last Name:TELLERMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2020 N LINCOLN PARK W
Mailing Address - Street 2:38J
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4780
Mailing Address - Country:US
Mailing Address - Phone:773-281-9034
Mailing Address - Fax:773-281-9036
Practice Address - Street 1:2020 N LINCOLN PARK W
Practice Address - Street 2:38J
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4780
Practice Address - Country:US
Practice Address - Phone:773-281-9034
Practice Address - Fax:773-281-9036
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL961620Medicare ID - Type Unspecified