MEDICARE: LYNNE M. SIMON PROFESSIONAL CORPORATION

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	071003423	IL

General Provider Information

NPI Number	:	1952504664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYNNE M. SIMON PROFESSIONAL CORPORATION

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 STE 619A
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-4586
Country	:	US
Telephone Number	:	847-328-8779
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LYNNE M. SIMON
Credential	:	PH.D.
Telephone Number	:	847-328-8779

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	03/05/2013

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