MEDICARE: DR. LYNNE MARTIN SIMON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist		IL

General Provider Information

NPI Number	:	1598722779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYNNE MARTIN SIMON PH.D.

Provider Business Mailing Address
First Line	:	404 CHURCH ST
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-4514
Country	:	US
Telephone Number	:	847-328-8779
Fax Number	:

Provider Business Practice Location Address
First Line	:	636 CHURCH ST
Second Line	:	619A
City	:	EVANSTON
State	:	IL
Zip	:	60201-4586
Country	:	US
Telephone Number	:	847-328-8779
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2006
Last Update Date	:	07/08/2007

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