Healthcare Provider Details

I. General information

NPI: 1932264207
Provider Name (Legal Business Name): GREGORY MALO PSYD & ASSOCIATES IN NEUROPSYCHOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 12/05/2022
Certification Date: 12/05/2022
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 TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number071002647
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: RANDALL WARREN SUMMERVILLE
Title or Position: OWNER
Credential:
Phone: 630-424-8900