Provider Demographics
NPI:1700644655
Name:MIRELLE D. BLOCH, PSY.D., LLC
Entity Type:Organization
Organization Name:MIRELLE D. BLOCH, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:872-226-2313
Mailing Address - Street 1:1328 GREENLEAF ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1153
Mailing Address - Country:US
Mailing Address - Phone:872-226-2313
Mailing Address - Fax:312-312-9675
Practice Address - Street 1:1328 GREENLEAF ST UNIT 4
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1153
Practice Address - Country:US
Practice Address - Phone:872-226-2313
Practice Address - Fax:312-312-9675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty