Provider Demographics
NPI:1386746501
Name:FARRELL, JOHN L (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:FARRELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 HICKORY RD
Mailing Address - Street 2:STE 103
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2158
Mailing Address - Country:US
Mailing Address - Phone:708-957-3695
Mailing Address - Fax:708-957-3695
Practice Address - Street 1:2024 HICKORY RD
Practice Address - Street 2:STE 103
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2158
Practice Address - Country:US
Practice Address - Phone:708-957-3662
Practice Address - Fax:708-957-3695
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003240103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL772682Medicare ID - Type Unspecified