Provider Demographics
NPI:1366441917
Name:PAUL, MARY ELIZABETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:PAUL
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 1:1526 W OHIO ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-6102
Mailing Address - Country:US
Mailing Address - Phone:312-455-0224
Mailing Address - Fax:
Practice Address - Street 1:1526 W OHIO ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-6102
Practice Address - Country:US
Practice Address - Phone:312-455-0224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-17
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-001694103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1672549OtherBLUE CROSS BLUE SHIELD IL
IL1672549OtherBLUE CROSS BLUE SHIELD IL