Provider Demographics
NPI:1740336502
Name:EDSTROM, KATHERINE E (PHD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTH MICHIGAN AVENUE
Mailing Address - Street 2:SUITE 717
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602
Mailing Address - Country:US
Mailing Address - Phone:312-629-5653
Mailing Address - Fax:708-445-0617
Practice Address - Street 1:30 NORTH MICHIGAN AVENUE
Practice Address - Street 2:SUITE 717
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602
Practice Address - Country:US
Practice Address - Phone:312-629-5653
Practice Address - Fax:708-445-0617
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
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
934861Medicare ID - Type Unspecified