MEDICARE: DR. THERESA CAMPBELL PH.D.

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	103G00000X	Clinical Neuropsychologist	071005976	IL

General Provider Information

NPI Number	:	1578506168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA CAMPBELL PH.D.

Provider Business Mailing Address
First Line	:	800 BIESTERFIELD RD STE 610
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3362
Country	:	US
Telephone Number	:	847-981-3630
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 BIESTERFIELD RD STE 610
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3362
Country	:	US
Telephone Number	:	847-981-3630
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	03/11/2021

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