MEDICARE: NORTH SHORE PSYCHOLOGICAL SERVICES LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071003138	IL

General Provider Information

NPI Number	:	1235265794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH SHORE PSYCHOLOGICAL SERVICES LTD

Provider Business Mailing Address
First Line	:	PO BOX 2257
Second Line	:
City	:	CHESTERTON
State	:	IN
Zip	:	46304-0357
Country	:	US
Telephone Number	:	219-926-8320
Fax Number	:	219-926-3524

Provider Business Practice Location Address
First Line	:	900 NORTH SHORE DR
Second Line	:	SUITE 200
City	:	LAKE BLUFF
State	:	IL
Zip	:	60044-2243
Country	:	US
Telephone Number	:	847-295-0340
Fax Number	:	847-295-0351

Authorized Official
Title or Position	:	PARTNER
Name	:	NEIL D MAHONEY
Credential	:	PHD
Telephone Number	:	847-295-0340

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	01/20/2015

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