Healthcare Provider Details

I. General information

NPI: 1063568210
Provider Name (Legal Business Name): GOLDSTEIN NEUROPSYCHOLOGISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2007
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S MICHIGAN AVE SUITE 710
CHICAGO IL
60604-2402
US

IV. Provider business mailing address

200 S MICHIGAN AVE SUITE 710
CHICAGO IL
60604-2402
US

V. Phone/Fax

Practice location:
  • Phone: 312-212-1776
  • Fax: 312-212-1778
Mailing address:
  • Phone: 312-212-1776
  • Fax: 312-212-1778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number20041441A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number071006006
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number20041441A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071006006
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041441A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071006006
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20041441A
License Number StateIN
# 8
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071006006
License Number StateIL

VIII. Authorized Official

Name: DR. DIANA SUSAN GOLDSTEIN
Title or Position: PRESIDENT & CEO
Credential: PH.D., ABPP
Phone: 312-212-1776