Provider Demographics
NPI:1104854892
Name:FLETCHER, TONY A (PSYD)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:A
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1244
Mailing Address - Country:US
Mailing Address - Phone:312-961-9974
Mailing Address - Fax:
Practice Address - Street 1:445 E OHIO ST
Practice Address - Street 2:SUITE 450
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3302
Practice Address - Country:US
Practice Address - Phone:312-961-9974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005279103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL424210Medicare ID - Type Unspecified
IL424210Medicare ID - Type Unspecified