Provider Demographics
NPI:1902286974
Name:DORNAK, TERRY (PSYD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:DORNAK
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 1:3525 W PETERSON AVE
Mailing Address - Street 2:STE 609
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3324
Mailing Address - Country:US
Mailing Address - Phone:847-532-3007
Mailing Address - Fax:847-972-6445
Practice Address - Street 1:6300 CORPORATE CT STE 103
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3513
Practice Address - Country:US
Practice Address - Phone:312-781-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009088103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF300323073Medicare PIN