Healthcare Provider Details

I. General information

NPI: 1235430612
Provider Name (Legal Business Name): PHC OF BUFFALO GROVE CLINICAL PSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 09/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E HAWTHORN PKWY SUITE 235
VERNON HILLS IL
60061-1463
US

IV. Provider business mailing address

175 E HAWTHORN PKWY SUITE 235
VERNON HILLS IL
60061-1463
US

V. Phone/Fax

Practice location:
  • Phone: 847-868-3435
  • Fax: 847-859-5885
Mailing address:
  • Phone: 847-868-3435
  • Fax: 847-859-5885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071007099
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164005333
License Number StateIL

VIII. Authorized Official

Name: JEREMY WARNER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 847-868-3435