Provider Demographics
NPI:1699770693
Name:AVELLONE, MARY ELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:AVELLONE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:211 E OHIO ST APT 520
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3220
Mailing Address - Country:US
Mailing Address - Phone:312-832-9858
Mailing Address - Fax:312-822-0712
Practice Address - Street 1:2024 HICKORY RD STE 104
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2158
Practice Address - Country:US
Practice Address - Phone:312-832-9858
Practice Address - Fax:312-822-0712
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005023103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1607451OtherBCBS IL
IL1607451OtherBCBS IL
IL356660Medicare ID - Type UnspecifiedMEDICARE ID