Provider Demographics
NPI:1477827640
Name:PODOLSKY, IRINA
Entity Type:Individual
Prefix:DR
First Name:IRINA
Middle Name:
Last Name:PODOLSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1623 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2343
Mailing Address - Country:US
Mailing Address - Phone:312-320-5137
Mailing Address - Fax:
Practice Address - Street 1:1623 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2343
Practice Address - Country:US
Practice Address - Phone:312-320-5137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008298103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical