Healthcare Provider Details

I. General information

NPI: 1225562986
Provider Name (Legal Business Name): ROBERT IDA PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1749 S NAPERVILLE RD SUITE 106
WHEATON IL
60189-5892
US

IV. Provider business mailing address

1749 S NAPERVILLE RD SUITE 106
WHEATON IL
60189-5892
US

V. Phone/Fax

Practice location:
  • Phone: 630-260-8780
  • Fax: 630-938-4697
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071009564
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071009564
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: