Healthcare Provider Details

I. General information

NPI: 1164402798
Provider Name (Legal Business Name): RICHARD NEAL BOLNICK PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 LAKEVIEW PKWY SUITE 110
VERNON HILLS IL
60061-1400
US

IV. Provider business mailing address

977 LAKEVIEW PKWY STE 110
VERNON HILLS IL
60061-1400
US

V. Phone/Fax

Practice location:
  • Phone: 847-549-6650
  • Fax: 847-549-7005
Mailing address:
  • Phone: 847-549-6650
  • Fax: 847-549-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-003331
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: