1659460715 NPI number — DR. TONYA MARIE MESTEMAKER PSY.D.

Table of content: DR. TONYA MARIE MESTEMAKER PSY.D. (NPI 1659460715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659460715 NPI number — DR. TONYA MARIE MESTEMAKER PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MESTEMAKER
Provider First Name:
TONYA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659460715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4443 N ALBANY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60625-4501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-383-7700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 N SHORE DR
Provider Second Line Business Practice Location Address:
SUITE 174
Provider Business Practice Location Address City Name:
LAKE BLUFF
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60044-2243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-383-7700
Provider Business Practice Location Address Fax Number:
847-615-1697
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04932470 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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