Healthcare Provider Details

I. General information

NPI: 1891095147
Provider Name (Legal Business Name): EIKO KOMURO VENOVIC PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MANCHESTER RD SUITE #1510
WHEATON IL
60187-4579
US

IV. Provider business mailing address

1929 CONWAY LN
AURORA IL
60503-8548
US

V. Phone/Fax

Practice location:
  • Phone: 630-653-1717
  • Fax:
Mailing address:
  • Phone: 630-479-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008008
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: