Provider Demographics
NPI:1689726572
Name:DOLEZAL, HUBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:HUBERT
Middle Name:
Last Name:DOLEZAL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 N LINCOLN PARK W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5487
Mailing Address - Country:US
Mailing Address - Phone:773-404-0160
Mailing Address - Fax:
Practice Address - Street 1:1960 N LINCOLN PARK W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-5487
Practice Address - Country:US
Practice Address - Phone:773-404-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL683730Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER