Healthcare Provider Details

I. General information

NPI: 1063048106
Provider Name (Legal Business Name): ELLIOTT NOLAN DEVORE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE STE 1909
CHICAGO IL
60602-3626
US

IV. Provider business mailing address

4970 N MARINE DR APT 322
CHICAGO IL
60640-3925
US

V. Phone/Fax

Practice location:
  • Phone: 773-362-6222
  • Fax:
Mailing address:
  • Phone: 865-599-4748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071011173
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: