Healthcare Provider Details

I. General information

NPI: 1174335111
Provider Name (Legal Business Name): DANIEL POLONSKY PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 DEERCREST LN
NORTHBROOK IL
60062-5074
US

IV. Provider business mailing address

1916 DEERCREST LN
NORTHBROOK IL
60062-5074
US

V. Phone/Fax

Practice location:
  • Phone: 847-449-6084
  • Fax:
Mailing address:
  • Phone: 847-449-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071.011398
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number03351
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.011398
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: