Provider Demographics
NPI:1023237286
Name:GITELSON, IDY BARASCH (PH D)
Entity type:Individual
Prefix:DR
First Name:IDY
Middle Name:BARASCH
Last Name:GITELSON
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2827 HARRISON STREET
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1217
Mailing Address - Country:US
Mailing Address - Phone:847-475-5686
Mailing Address - Fax:
Practice Address - Street 1:2827 HARRISON STREET
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1217
Practice Address - Country:US
Practice Address - Phone:847-475-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical