Provider Demographics
NPI:1881768489
Name:RUBIN, PHYLLIS B (PSY D)
Entity type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:B
Last Name:RUBIN
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 LAKE ST
Mailing Address - Street 2:SUITE 720
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301
Mailing Address - Country:US
Mailing Address - Phone:708-848-0983
Mailing Address - Fax:708-848-0465
Practice Address - Street 1:715 LAKE ST
Practice Address - Street 2:SUITE 720
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301
Practice Address - Country:US
Practice Address - Phone:708-848-0983
Practice Address - Fax:708-848-0465
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005880103T00000X
IL146001732235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3781254014Medicaid
IL31623351OtherBCBS
IL31623353OtherBCBS
IL3781254014Medicaid