MEDICARE: DIRKSEN CENTER FOR NEUROPSYCHOLOGY, LTD

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	103G00000X	Clinical Neuropsychologist

General Provider Information

NPI Number	:	1871733444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIRKSEN CENTER FOR NEUROPSYCHOLOGY, LTD

Provider Business Mailing Address
First Line	:	PO BOX 45
Second Line	:
City	:	PORTAGE
State	:	IN
Zip	:	46368-0045
Country	:	US
Telephone Number	:	219-926-8320
Fax Number	:	219-926-3524

Provider Business Practice Location Address
First Line	:	855 E GOLF RD
Second Line	:	SUITE 1127
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-5222
Country	:	US
Telephone Number	:	847-347-9288
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	TRACY FREEZE
Credential	:
Telephone Number	:	219-926-8320

Provider Enumeration Date	:	02/23/2009
Last Update Date	:	03/05/2010

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