=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710321229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR NEUROBEHAVIORAL DISORDERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2013
-----------------------------------------------------
Last Update Date | 04/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2490 N WATER ST SUITE 9
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-4251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-877-1100
-----------------------------------------------------
Fax | 217-877-1101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2490 N WATER ST SUITE 9
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-4251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-877-1100
-----------------------------------------------------
Fax | 217-877-1101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NEUROPSYCHOLOGIST
-----------------------------------------------------
Name | DR. KAREN ELENA LEE
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 217-877-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 071004726
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------