Healthcare Provider Details

I. General information

NPI: 1720579691
Provider Name (Legal Business Name): BRIAN G VANMEURS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

1675 DEMPSTER ST
PARK RIDGE IL
60068-1110
US

V. Phone/Fax

Practice location:
  • Phone: 617-851-5530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071.009799
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009799
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: