Provider Demographics
NPI:1558626267
Name:BRIETZKE, COLIN A (PSY D)
Entity type:Individual
Prefix:DR
First Name:COLIN
Middle Name:A
Last Name:BRIETZKE
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 LAKE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1137
Mailing Address - Country:US
Mailing Address - Phone:708-320-1411
Mailing Address - Fax:708-328-3560
Practice Address - Street 1:1011 LAKE ST STE 200
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1137
Practice Address - Country:US
Practice Address - Phone:708-320-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008376103TC0700X, 103TC2200X
IL071.008376103TF0200X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty