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General NPI Number Information
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NPI Number | 1285641472
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Entity Type | Organization
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Legal Business Name | BRIAN TIMOTHY MADVIG
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 06/17/2008
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Provider Practice Location Address
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Address Line | 1725 S NAPERVILLE RD SUITE 207
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City | WHEATON
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State | IL
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Zip | 60187-8155
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Country | US
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Telephone | 630-462-7005
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Fax | 630-462-7006
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Provider Business Mailing Address
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Address Line | 1725 S NAPERVILLE RD SUITE 207
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City | WHEATON
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State | IL
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Zip | 60187-8155
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Country | US
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Telephone | 630-462-7005
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Fax | 630-462-7006
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Authorized Official
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Title or Position | OWNER
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Name | BRIAN T. MADVIG
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Credential | PH.D.
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Telephone | 630-462-7005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071-005079
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License Number State | IL
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