Provider Demographics
NPI:1336453265
Name:WALLACH, JOSEPH ELI (PHD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ELI
Last Name:WALLACH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 W GREENLEAF AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-3013
Mailing Address - Country:US
Mailing Address - Phone:773-852-2400
Mailing Address - Fax:773-856-3517
Practice Address - Street 1:2530 CRAWFORD AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4970
Practice Address - Country:US
Practice Address - Phone:773-852-2400
Practice Address - Fax:847-869-8116
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007942103TB0200X, 103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth