Healthcare Provider Details

I. General information

NPI: 1366079907
Provider Name (Legal Business Name): COLBY PAUL WILEY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 RANDALL RD STE 308
GENEVA IL
60134-4205
US

IV. Provider business mailing address

302 RANDALL RD STE 308
GENEVA IL
60134-4205
US

V. Phone/Fax

Practice location:
  • Phone: 630-524-5845
  • Fax: 630-208-3007
Mailing address:
  • Phone: 630-524-5845
  • Fax: 630-208-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071010334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: