Provider Demographics
NPI:1063716892
Name:RYDBERG, THAD S (MA, LCPC)
Entity type:Individual
Prefix:
First Name:THAD
Middle Name:S
Last Name:RYDBERG
Suffix:
Gender:M
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3139 N LINCOLN AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3122
Mailing Address - Country:US
Mailing Address - Phone:773-726-3295
Mailing Address - Fax:
Practice Address - Street 1:3139 N LINCOLN AVE STE 203
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3122
Practice Address - Country:US
Practice Address - Phone:773-726-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-09
Last Update Date:2011-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005506101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health