Provider Demographics
NPI:1497200547
Name:POLLMANN, MARISSA A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:A
Last Name:POLLMANN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21601 N INGLENOOK LN
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60010-9728
Mailing Address - Country:US
Mailing Address - Phone:773-416-7639
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010398103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid