Provider Demographics
NPI:1326622622
Name:BANK, JUDITH MERYL (PHD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:MERYL
Last Name:BANK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E DELAWARE PL APT 3C
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-1749
Mailing Address - Country:US
Mailing Address - Phone:312-543-5400
Mailing Address - Fax:
Practice Address - Street 1:200 E DELAWARE PL APT 3C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-1749
Practice Address - Country:US
Practice Address - Phone:312-543-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-001730102L00000X
ID149-001730101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-001730OtherPERSONAL
IL149-001730OtherLICENSE