Individual
DR. K. JOD TAYWADITEP
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
633 EMERSON ST, EVANSTON, IL 60208-0844
(847) 491-2151
Mailing address
633 EMERSON ST, EVANSTON, IL 60208-0844
(847) 491-2151
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
71006528
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01634395
BLUE CROSS BLUE SHIELD
IL
Enumeration date
09/06/2006
Last updated
07/07/2009
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