Provider Demographics
NPI:1194851477
Name:WOLFSON PSYCHOLOGICAL SERVICES, P.C.
Entity Type:Organization
Organization Name:WOLFSON PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOLFSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-433-4450
Mailing Address - Street 1:149 OAK KNOLL TER
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-5320
Mailing Address - Country:US
Mailing Address - Phone:847-433-4450
Mailing Address - Fax:847-433-5464
Practice Address - Street 1:149 OAK KNOLL TER
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-5320
Practice Address - Country:US
Practice Address - Phone:847-433-4450
Practice Address - Fax:847-433-5464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005558103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211404Medicare ID - Type UnspecifiedMEDICARE GROUP PROVIDER #
ILS96610Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ILK16447Medicare ID - Type UnspecifiedMEDICARE MEMBER #