Provider Demographics
NPI:1972146181
Name:RANDELOVA, PETYA (PSYD)
Entity type:Individual
Prefix:
First Name:PETYA
Middle Name:
Last Name:RANDELOVA
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 1:155 N MICHIGAN AVE STE 624
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7795
Mailing Address - Country:US
Mailing Address - Phone:872-395-8091
Mailing Address - Fax:
Practice Address - Street 1:155 N MICHIGAN AVE STE 624
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7795
Practice Address - Country:US
Practice Address - Phone:872-395-8091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010143103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical