=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912531237
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NOELLE KATHLEEN PONTARELLI PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2020
-----------------------------------------------------
Last Update Date | 02/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3330 OLD GLENVIEW RD STE 10
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-2963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-867-2326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3330 OLD GLENVIEW RD STE 10
-----------------------------------------------------
City | WILMETTE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60091-2963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-867-2326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071010256
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------