Basic Information
Provider Information | |||||||||
NPI: | 1235560590 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOLOK | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | BETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GIVEN | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | BETH | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 950 LEE ST | ||||||||
Address2: | 212 | ||||||||
City: | DES PLAINES | ||||||||
State: | IL | ||||||||
PostalCode: | 600166532 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474864140 | ||||||||
FaxNumber: | 8474864145 | ||||||||
Practice Location | |||||||||
Address1: | 950 LEE ST | ||||||||
Address2: | 212 | ||||||||
City: | DES PLAINES | ||||||||
State: | IL | ||||||||
PostalCode: | 600166532 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8474864140 | ||||||||
FaxNumber: | 8474864145 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2013 | ||||||||
LastUpdateDate: | 12/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 071008721 | IL | N |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   | 103TC0700X | 071008721 | IL | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 071008721 | IL | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.