Healthcare Provider Details

I. General information

NPI: 1922766526
Provider Name (Legal Business Name): SUMMERVILLE NEUROPSYCHOLOGY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N SHEFFIELD AVE STE 214
CHICAGO IL
60657-5083
US

IV. Provider business mailing address

477 E BUTTERFIELD RD STE 102
LOMBARD IL
60148-4880
US

V. Phone/Fax

Practice location:
  • Phone: 630-424-8900
  • Fax:
Mailing address:
  • Phone: 630-424-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: RANDALL SUMMERVILLE
Title or Position: OWNER
Credential: PSYD
Phone: 630-424-8900