Provider Demographics
NPI:1881236917
Name:BLOCH, MIRELLE DAVIS (PSYD)
Entity type:Individual
Prefix:DR
First Name:MIRELLE
Middle Name:DAVIS
Last Name:BLOCH
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 1:1031 WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1160
Mailing Address - Country:US
Mailing Address - Phone:872-226-2313
Mailing Address - Fax:
Practice Address - Street 1:4305 N LINCOLN AVE STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1807
Practice Address - Country:US
Practice Address - Phone:872-226-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010127103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical