Healthcare Provider Details

I. General information

NPI: 1891791554
Provider Name (Legal Business Name): ROBERT BRUCE HENRY PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 WALDEN OFFICE SQ STE 400
SCHAUMBURG IL
60173-4273
US

IV. Provider business mailing address

5846 N SAINT JOHNS CT
CHICAGO IL
60646-6047
US

V. Phone/Fax

Practice location:
  • Phone: 847-925-5115
  • Fax: 877-700-8148
Mailing address:
  • Phone: 847-619-6499
  • Fax: 877-700-8148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-002757
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: