Provider Demographics
NPI:1013030725
Name:GREAT LAKES NEUROPSYCHOLOGY & COUNSELING LLC
Entity Type:Organization
Organization Name:GREAT LAKES NEUROPSYCHOLOGY & COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST/MEMB
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BONG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:815-231-1280
Mailing Address - Street 1:5758 ELAINE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-3102
Mailing Address - Country:US
Mailing Address - Phone:815-231-1280
Mailing Address - Fax:815-231-1282
Practice Address - Street 1:5758 ELAINE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-3102
Practice Address - Country:US
Practice Address - Phone:815-231-1280
Practice Address - Fax:815-231-1282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103G00000X, 103G00000X, 103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215368OtherMEDICARE PTAN