Healthcare Provider Details

I. General information

NPI: 1790117208
Provider Name (Legal Business Name): ILLINOIS NEUROTHERAPY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 MAIN ST STE 210
DOWNERS GROVE IL
60516-3493
US

IV. Provider business mailing address

6800 MAIN ST STE 210
DOWNERS GROVE IL
60516-3493
US

V. Phone/Fax

Practice location:
  • Phone: 630-210-4863
  • Fax:
Mailing address:
  • Phone: 630-210-4863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012062
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038010254
License Number StateIL

VIII. Authorized Official

Name: KAREN ROACH
Title or Position: OWNER
Credential: LCSW
Phone: 630-210-4863