Provider Demographics
NPI:1083342299
Name:RIVERSIDE PSYCHOLOGY
Entity Type:Organization
Organization Name:RIVERSIDE PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDASSARRE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-762-9602
Mailing Address - Street 1:7627 LAKE ST STE 222
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1806
Mailing Address - Country:US
Mailing Address - Phone:708-762-9602
Mailing Address - Fax:
Practice Address - Street 1:7627 LAKE ST STE 222
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1806
Practice Address - Country:US
Practice Address - Phone:708-762-9602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-15
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty