Healthcare Provider Details

I. General information

NPI: 1609043553
Provider Name (Legal Business Name): DAVID EDWARD VICTORSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2008
Last Update Date: 05/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 CHESTNUT AVE GLENVIEW PARK CENTER - INTEGRATIVE MEDICINE, SUITE A
GLENVIEW IL
60026-8321
US

IV. Provider business mailing address

2650 RIDGE AVE EVANSTON HOSPITAL
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-657-3540
  • Fax: 847-657-3530
Mailing address:
  • Phone: 847-570-1206
  • Fax: 847-570-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-007103
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: