Provider Demographics
NPI:1205895430
Name:POVOLNY, MARY ALICE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY ALICE
Middle Name:
Last Name:POVOLNY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 N YORK RD
Mailing Address - Street 2:SUITE B1
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126
Mailing Address - Country:US
Mailing Address - Phone:630-415-0780
Mailing Address - Fax:
Practice Address - Street 1:331 N YORK RD
Practice Address - Street 2:SUITE B1
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126
Practice Address - Country:US
Practice Address - Phone:630-415-0780
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
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
IL02222501OtherBC
IL02222501OtherBC
IL436170Medicare ID - Type Unspecified