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General NPI Number Information
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NPI Number | 1245742865
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Entity Type | Organization
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Legal Business Name | NEUROREHAB PSYCHOLOGY CONSULTANTS, LLC
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Dates
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Enumeration Date | 11/05/2017
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Last Update Date | 04/26/2018
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Provider Practice Location Address
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Address Line | 419 CENTER ST STE C
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City | GRAYSLAKE
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State | IL
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Zip | 60030-1645
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Country | US
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Telephone | 262-412-7302
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Fax |
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Provider Business Mailing Address
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Address Line | 11314 E RIVIERA DR
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City | SPRING GROVE
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State | IL
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Zip | 60081-8146
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Country | US
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Telephone | 262-412-7302
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST/PRESIDENT
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Name | DR. DANIELLE M CICCONE-COUTRE
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Credential | PSYD
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Telephone | 262-412-7302
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TR0400X
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Taxonomy Name | Rehabilitation Psychologist
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License Number | 071.009251
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License Number State | IL
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