Healthcare Provider Details

I. General information

NPI: 1093074502
Provider Name (Legal Business Name): CHICAGO NEUROPSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 05/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E ERIE ST SUITE 353
CHICAGO IL
60611-2740
US

IV. Provider business mailing address

1 E ERIE ST SUITE 353
CHICAGO IL
60611-2740
US

V. Phone/Fax

Practice location:
  • Phone: 312-863-3033
  • Fax: 312-262-4880
Mailing address:
  • Phone: 312-863-3033
  • Fax: 312-262-4880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071004821
License Number StateIL

VIII. Authorized Official

Name: DR. CHRISTOPHER RANDOLPH
Title or Position: DIRECTOR
Credential: PHD
Phone: 312-863-3033