Provider Demographics
NPI:1083168041
Name:KOSTYSHYNA, TETYANA (PSYD, LCPC, LSOE/TP)
Entity type:Individual
Prefix:DR
First Name:TETYANA
Middle Name:
Last Name:KOSTYSHYNA
Suffix:
Gender:F
Credentials:PSYD, LCPC, LSOE/TP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S RANDALL RD STE 204
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-5918
Mailing Address - Country:US
Mailing Address - Phone:312-818-9300
Mailing Address - Fax:888-488-2604
Practice Address - Street 1:555 S RANDALL RD STE 204
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5918
Practice Address - Country:US
Practice Address - Phone:312-818-9300
Practice Address - Fax:888-488-2604
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3415 - 57103T00000X
IL180009177101YM0800X
IL071.009432103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health