Provider Demographics
NPI:1720614407
Name:MEDEMA, RACHEL
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:MEDEMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4845 N WASHTENAW AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2826
Mailing Address - Country:US
Mailing Address - Phone:262-994-6404
Mailing Address - Fax:
Practice Address - Street 1:1901 N CLYBOURN AVE STE 304
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6808
Practice Address - Country:US
Practice Address - Phone:773-697-8839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013414101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional