Healthcare Provider Details

I. General information

NPI: 1821180803
Provider Name (Legal Business Name): RANDALL WARREN SUMMERVILLE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 12/05/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 E BUTTERFIELD RD STE 102
LOMBARD IL
60148-4880
US

IV. Provider business mailing address

477 E BUTTERFIELD RD STE 102
LOMBARD IL
60148-4880
US

V. Phone/Fax

Practice location:
  • Phone: 630-424-8900
  • Fax: 630-424-9017
Mailing address:
  • Phone: 630-424-8900
  • Fax: 630-424-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071-006658
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number071-006658
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-006658
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: