Provider Demographics
NPI:1104965565
Name:SEGAL, EVELYN (PHD)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:SEGAL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S FIRST AVE
Mailing Address - Street 2:(FAHEY BLDG., RM. 222)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-216-3750
Mailing Address - Fax:708-216-6840
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(FAHEY BLDG., RM. 222)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3750
Practice Address - Fax:708-216-6840
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004756103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK24099Medicare ID - Type Unspecified
ILK24135Medicare ID - Type Unspecified