Healthcare Provider Details

I. General information

NPI: 1275946048
Provider Name (Legal Business Name): CHICAGOLAND NEUROPSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N MARION ST STE 313
OAK PARK IL
60301-1167
US

IV. Provider business mailing address

101 N MARION ST STE. 313
OAK PARK IL
60301-1167
US

V. Phone/Fax

Practice location:
  • Phone: 773-931-3439
  • Fax:
Mailing address:
  • Phone: 773-931-3439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071.008376
License Number StateIL

VIII. Authorized Official

Name: COLIN BRIETZKE
Title or Position: OWNER
Credential: PSY.D.
Phone: 773-931-3439