Provider Demographics
NPI:1063504124
Name:PASULKA, PAUL (PHD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PASULKA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-003338103G00000X, 103T00000X, 103TC0700X, 103TC2200X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01673053OtherBLUE CROSS BLUE SHIELD
IL01673053OtherBLUE CROSS BLUE SHIELD
IL620004714Medicare ID - Type UnspecifiedRAILROAD MEDICARE