Healthcare Provider Details

I. General information

NPI: 1629478599
Provider Name (Legal Business Name): GANESHA INSTITUTE OF NEUROLOGY AND PSYCHIATRY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 W WINCHESTER RD STE 106
LIBERTYVILLE IL
60048-5312
US

IV. Provider business mailing address

1860 W WINCHESTER RD STE 106
LIBERTYVILLE IL
60048-5312
US

V. Phone/Fax

Practice location:
  • Phone: 847-816-6335
  • Fax: 847-816-6355
Mailing address:
  • Phone: 847-816-6335
  • Fax: 847-816-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LORI A SMITH
Title or Position: PRACTICE MANAGER
Credential:
Phone: 847-816-6441