Healthcare Provider Details

I. General information

NPI: 1902477953
Provider Name (Legal Business Name): MICHELLE DEMARAY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 KEIM CIR
GENEVA IL
60134-7516
US

IV. Provider business mailing address

1412 KEIM CIR
GENEVA IL
60134-7516
US

V. Phone/Fax

Practice location:
  • Phone: 630-452-5633
  • Fax:
Mailing address:
  • Phone: 630-452-5633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.008850
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1817502
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: