Healthcare Provider Details

I. General information

NPI: 1578890018
Provider Name (Legal Business Name): KATHLEEN MARIE NUGENT PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 REVERE DR SUITE 100
NORTHBROOK IL
60062-1563
US

IV. Provider business mailing address

612 OUILMETTE LN
WILMETTE IL
60091-2316
US

V. Phone/Fax

Practice location:
  • Phone: 224-306-1879
  • Fax:
Mailing address:
  • Phone: 847-853-9413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071007637
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071007637
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number071007637
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number071007637
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number071007637
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: