Provider Demographics
NPI:1053686717
Name:PAUL PASULKA, PH.D., P.C.
Entity Type:Organization
Organization Name:PAUL PASULKA, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PASULKA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-266-2136
Mailing Address - Street 1:600 N MCCLURG CT
Mailing Address - Street 2:SUITE 3803A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3044
Mailing Address - Country:US
Mailing Address - Phone:312-266-2136
Mailing Address - Fax:312-266-6375
Practice Address - Street 1:600 N MCCLURG CT
Practice Address - Street 2:SUITE 3803A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3044
Practice Address - Country:US
Practice Address - Phone:312-266-2136
Practice Address - Fax:312-266-6375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071000013103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1063504124OtherINDIVIDUAL NPI
IL796290Medicare PIN