Basic Information
| Provider Information | |||||||||
| NPI: | 1629047469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSTAS | ||||||||
| FirstName: | KONSTANTINOS | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KOSTAS | ||||||||
| OtherFirstName: | DINO | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4501 N WINCHESTER AVE | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732500500 | ||||||||
| FaxNumber: | 7732500497 | ||||||||
| Practice Location | |||||||||
| Address1: | 4501 N WINCHESTER AVE | ||||||||
| Address2: | 2ND FL | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732500500 | ||||||||
| FaxNumber: | 7732500497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071005172 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.