Provider Demographics
NPI:1356922561
Name:CHAMBERLAIN, MICHAEL (PSYD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CHAMBERLAIN
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 1:6851 S EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-4118
Mailing Address - Country:US
Mailing Address - Phone:503-312-1635
Mailing Address - Fax:
Practice Address - Street 1:1025 W SUNNYSIDE AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5684
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-388-8936
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010508103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071.010508Medicaid