Healthcare Provider Details

I. General information

NPI: 1407604291
Provider Name (Legal Business Name): BEDROCK PSYCHOLOGY GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 WILLOW RD STE 101
NORTHFIELD IL
60093-3450
US

IV. Provider business mailing address

1063 FOREST AVE
DEERFIELD IL
60015-2920
US

V. Phone/Fax

Practice location:
  • Phone: 773-389-2352
  • Fax:
Mailing address:
  • Phone: 773-575-0466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL LOSOFF
Title or Position: FOUNDER / CLINICAL PSYCHOLOGIST
Credential:
Phone: 773-389-2352