Provider Demographics
NPI:1669431912
Name:DELLORTO, MARY K (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:K
Last Name:DELLORTO
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 1:2412 E WASHINGTON ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4497
Mailing Address - Country:US
Mailing Address - Phone:309-664-6952
Mailing Address - Fax:309-664-7522
Practice Address - Street 1:2412 E WASHINGTON ST
Practice Address - Street 2:SUITE 3
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4497
Practice Address - Country:US
Practice Address - Phone:309-664-6952
Practice Address - Fax:309-664-7522
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004397103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL520420Medicare ID - Type Unspecified