Healthcare Provider Details

I. General information

NPI: 1386848083
Provider Name (Legal Business Name): BRIAN KEITH PRICE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 29216
APO AE
09102
US

IV. Provider business mailing address

1005 JENKISSON AVE
LAKE BLUFF IL
60044-1623
US

V. Phone/Fax

Practice location:
  • Phone: 33388848592
  • Fax:
Mailing address:
  • Phone: 312-972-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.007309
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: