Provider Demographics
NPI:1043366297
Name:STEIN, GERALD M (PHD)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:M
Last Name:STEIN
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 1:210 W 22ND ST
Mailing Address - Street 2:SUITE 118
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1544
Mailing Address - Country:US
Mailing Address - Phone:630-571-1077
Mailing Address - Fax:
Practice Address - Street 1:210 W 22ND ST
Practice Address - Street 2:SUITE 118
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1544
Practice Address - Country:US
Practice Address - Phone:630-571-1077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-001939103G00000X, 103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071-001939OtherLICENSE
IL022-72048-74OtherBLUE CROSS BLUE SHIELD
IL730-700Medicare ID - Type Unspecified