Healthcare Provider Details

I. General information

NPI: 1003221755
Provider Name (Legal Business Name): LIFESPAN NEURODEVELOPMENTAL CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 N DEARBORN ST SUITE #1600
CHICAGO IL
60602-3102
US

IV. Provider business mailing address

33 N DEARBORN ST SUITE #1600
CHICAGO IL
60602-3102
US

V. Phone/Fax

Practice location:
  • Phone: 847-421-0122
  • Fax: 312-781-6706
Mailing address:
  • Phone: 847-421-0122
  • Fax: 312-781-6706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071008839
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number071008839
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008839
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number071008839
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number071008839
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number071008839
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number071008839
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number071008839
License Number StateIL

VIII. Authorized Official

Name: DR. MATTHEW PAUL RICHMOND
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 847-421-0122