Provider Demographics
NPI:1710962139
Name:ISYANOV, YEVGENIY (PHD)
Entity Type:Individual
Prefix:DR
First Name:YEVGENIY
Middle Name:
Last Name:ISYANOV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:EUGENE
Other - Middle Name:
Other - Last Name:ISYANOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:803 S POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-4544
Mailing Address - Country:US
Mailing Address - Phone:847-673-8577
Mailing Address - Fax:
Practice Address - Street 1:8707 SKOKIE BLVD STE 207
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2269
Practice Address - Country:US
Practice Address - Phone:847-673-8577
Practice Address - Fax:847-568-0411
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-004766101YM0800X, 101YP2500X
103K00000X, 101YA0400X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180-004766OtherIL LICENSE NUMBER