Provider Demographics
NPI:1003221755
Name:LIFESPAN NEURODEVELOPMENTAL CONSULTANTS
Entity Type:Organization
Organization Name:LIFESPAN NEURODEVELOPMENTAL CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:RICHMOND
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-421-0122
Mailing Address - Street 1:33 N DEARBORN ST
Mailing Address - Street 2:SUITE #1600
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3102
Mailing Address - Country:US
Mailing Address - Phone:847-421-0122
Mailing Address - Fax:312-781-6706
Practice Address - Street 1:33 N DEARBORN ST
Practice Address - Street 2:SUITE #1600
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3102
Practice Address - Country:US
Practice Address - Phone:847-421-0122
Practice Address - Fax:312-781-6706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008839103G00000X, 103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103TH0004X, 103TM1800X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Multi-Specialty