Provider Demographics
NPI:1104874494
Name:ROMM, STEPHAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:
Last Name:ROMM
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 1:2353 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2662
Mailing Address - Country:US
Mailing Address - Phone:847-328-3350
Mailing Address - Fax:847-491-6287
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE419A
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4508
Practice Address - Country:US
Practice Address - Phone:847-328-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004931103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL273939000OtherMAGELLAN
IL216-06218OtherBCBS ID #
IL232373643OtherUNITED BEHAVIORAL HEALTH
IL782-5241OtherAETNA
ILR85696Medicare UPIN
IL216-06218OtherBCBS ID #