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General NPI Number Information
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NPI Number | 1962916015
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Entity Type | Organization
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Legal Business Name | IRINA PODOLSKY PSYD LLC
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Dates
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Enumeration Date | 11/28/2017
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Last Update Date | 11/13/2018
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Provider Practice Location Address
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Address Line | 1623 W MAIN ST
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City | FAIRFIELD
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State | IL
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Zip | 62837-2343
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Country | US
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Telephone | 312-320-5137
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 278
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City | FAIRFIELD
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State | IL
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Zip | 62837-0278
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. IRINA PODOLSKY
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Credential | PSYD
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Telephone | 312-320-5137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 073.000074
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License Number State | IL
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