Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 071-003338 | IL |
Y | 103TC0700X | Clinical Psychologist | 071-003338 | IL |
N | 102L00000X | Psychologist | 071-003338 | IL |
N | 103T00000X | Psychologist | 071-003338 | IL |
N | 103G00000X | Clinical Psychologist | 071-003338 | IL |
N | 103TC0700X | Clinical Psychologist | 071-003338 | IL |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 071-003338 | IL |
N | 103TF0200X | Forensic Psychologist | 071-003338 | IL |
NPI | 1063504124 |
---|---|
Provider Name | Paul Pasulka |
First Address | Chicago, IL 60611-3044 |
Second Address | Chicago, IL 60611-3044 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2006 |
Last Update Date | 12/10/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01673053 | BLUE CROSS BLUE SHIELD (01) | IL |