Provider Demographics
NPI:1144376229
Name:CORMALLETH, PAULA RUTH (PSY D)
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:RUTH
Last Name:CORMALLETH
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 E WACKER DRIVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601
Mailing Address - Country:US
Mailing Address - Phone:312-553-9010
Mailing Address - Fax:
Practice Address - Street 1:75 E WACKER DRIVE
Practice Address - Street 2:SUITE 600
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601
Practice Address - Country:US
Practice Address - Phone:312-553-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0001673076OtherBLUE CROSS BLUE SHIELD
IL343560Medicare ID - Type Unspecified
WI343560Medicare ID - Type Unspecified