MEDICARE: DR. IVONNE HERAS HOBFOLL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071003526	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R03903	OTHER		SUMMA
2	4130254	OTHER		AETNA

General Provider Information

NPI Number	:	1679688246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVONNE HERAS HOBFOLL PH.D.

Provider Business Mailing Address
First Line	:	1653 W CONGRESS PARKWAY
Second Line	:	RUSH UNIVERSITY MEDICAL CENTER-DEPT. BEHAVIORAL SCIENCE
City	:	CHICAGO
State	:	IL
Zip	:	60612-3244
Country	:	US
Telephone Number	:	312-942-5932
Fax Number	:	312-942-4990

Provider Business Practice Location Address
First Line	:	1653 W CONGRESS PARKWAY
Second Line	:	RUSH UNIVERSITY MEDICAL CENTER-DEPT. BEHAVIORAL SCIENCE
City	:	CHICAGO
State	:	IL
Zip	:	60612-3244
Country	:	US
Telephone Number	:	312-942-5932
Fax Number	:	312-942-4990

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	06/27/2011

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