Provider Demographics
NPI:1124350418
Name:RAVIV, TAL (PHD)
Entity type:Individual
Prefix:
First Name:TAL
Middle Name:
Last Name:RAVIV
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TALI
Other - Middle Name:
Other - Last Name:RAVIV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2300 N CHILDRENS PLZ
Mailing Address - Street 2:BOX 10
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3363
Mailing Address - Country:US
Mailing Address - Phone:773-880-4827
Mailing Address - Fax:773-880-8110
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:BOX 10
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-880-4827
Practice Address - Fax:773-880-8110
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007797103T00000X
CO3336103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist