=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194412262
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAURA URBAN PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2023
-----------------------------------------------------
Last Update Date | 09/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2610 LAKE COOK RD STE 133
-----------------------------------------------------
City | RIVERWOODS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-920-7187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2610 LAKE COOK RD STE 133
-----------------------------------------------------
City | RIVERWOODS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-5710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-920-7187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 071.010963
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071.010963
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 071.010963
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------