Healthcare Provider Details

I. General information

NPI: 1275738130
Provider Name (Legal Business Name): SHARED VISION PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HARGER RD #600
OAK BROOK IL
60523
US

IV. Provider business mailing address

1200 HARGER RD #600
OAK BROOK IL
60523
US

V. Phone/Fax

Practice location:
  • Phone: 630-571-5750
  • Fax: 630-571-5751
Mailing address:
  • Phone: 630-571-5750
  • Fax: 630-571-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MYRA M. LAWRENCE
Title or Position: CEO
Credential: PSY.D.
Phone: 630-571-1110