MEDICARE: NEUROBEHAVIORAL GROUP PC

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	071007744	IL
2	103G00000X	Clinical Neuropsychologist	071007744	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IL8063	OTHER	IL	PTAN

General Provider Information

NPI Number	:	1992051130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEUROBEHAVIORAL GROUP PC

Provider Business Mailing Address
First Line	:	1755 PARK ST
Second Line	:	#200
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-4861
Country	:	US
Telephone Number	:	630-449-4270
Fax Number	:	630-820-2358

Provider Business Practice Location Address
First Line	:	1755 PARK ST
Second Line	:	#200
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-4861
Country	:	US
Telephone Number	:	630-449-4270
Fax Number	:	630-820-2358

Authorized Official
Title or Position	:	OWNER
Name	:	MICHELLE R MYERS
Credential	:	PSY.D.
Telephone Number	:	773-972-4248

Provider Enumeration Date	:	07/25/2012
Last Update Date	:	11/01/2013

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