Healthcare Provider Details

I. General information

NPI: 1023189792
Provider Name (Legal Business Name): DAVID DEAN BROCKMAN MD SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 KENILWORTH LANE DAVID DEAN BROCKMAN MD SC
GLENVIEW FL
60025
US

IV. Provider business mailing address

1030 KENILWORTH LANE DAVID DEAN BROCKMAN MD SC
GLENVIEW IL
60025
US

V. Phone/Fax

Practice location:
  • Phone: 847-729-0932
  • Fax:
Mailing address:
  • Phone:
  • Fax: 847-729-2519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number303699
License Number StateIL

VIII. Authorized Official

Name: DR. DAVID DEAN BROCKMAN
Title or Position: PRESIDENT
Credential:
Phone: 847-729-0932