Healthcare Provider Details

I. General information

NPI: 1750036331
Provider Name (Legal Business Name): BLUE LOTUS NEUROPSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2022
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 CHURCH ST STE 307
EVANSTON IL
60201-4579
US

IV. Provider business mailing address

636 CHURCH ST STE 307
EVANSTON IL
60201-4579
US

V. Phone/Fax

Practice location:
  • Phone: 847-220-4365
  • Fax:
Mailing address:
  • Phone: 847-220-4365
  • 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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. CHELSEA COOPER
Title or Position: MANAGING PARTNER
Credential: PSY.D.
Phone: 847-220-4365