Provider Demographics
NPI:1487689972
Name:KORDON, MARSHALL ELLIOTT (PSYD)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:ELLIOTT
Last Name:KORDON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 N RAVENSWOOD AVE STE 239
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1752
Mailing Address - Country:US
Mailing Address - Phone:773-267-3703
Mailing Address - Fax:773-267-3703
Practice Address - Street 1:5100 N RAVENSWOOD AVE STE 239
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1752
Practice Address - Country:US
Practice Address - Phone:773-267-3703
Practice Address - Fax:773-267-3703
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.005308103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364256529OtherUNITED BEHAVIORAL HEALTH
IL01621915OtherBLUE CROSS BLUE SHIELD