Healthcare Provider Details

I. General information

NPI: 1699770693
Provider Name (Legal Business Name): MARY ELIZABETH AVELLONE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 HICKORY RD STE 104
HOMEWOOD IL
60430-2158
US

IV. Provider business mailing address

211 E OHIO ST APT 520
CHICAGO IL
60611-3220
US

V. Phone/Fax

Practice location:
  • Phone: 312-832-9858
  • Fax: 312-822-0712
Mailing address:
  • Phone: 312-832-9858
  • Fax: 312-822-0712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071005023
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005023
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: