Healthcare Provider Details

I. General information

NPI: 1730777350
Provider Name (Legal Business Name): CENTER FOR COMPREHENSIVE NEUROBEHAVIORAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 E WACKER PL STE 300
CHICAGO IL
60601-7203
US

IV. Provider business mailing address

65 E WACKER PL STE 300
CHICAGO IL
60601-7203
US

V. Phone/Fax

Practice location:
  • Phone: 801-953-4371
  • Fax:
Mailing address:
  • Phone: 801-953-4371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LORI G TALL
Title or Position: EXECUTIVE DIRECTOR
Credential: PSYD
Phone: 801-953-4371