Provider Demographics
NPI:1952401945
Name:FEDOR, HOLLY MOAK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:MOAK
Last Name:FEDOR
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 1:12034 MEADOWLAND DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9279
Mailing Address - Country:US
Mailing Address - Phone:708-301-4071
Mailing Address - Fax:
Practice Address - Street 1:13011 S 104TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1506
Practice Address - Country:US
Practice Address - Phone:708-448-3300
Practice Address - Fax:708-448-6972
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
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