Provider Demographics
NPI:1093074502
Name:CHICAGO NEUROPSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:CHICAGO NEUROPSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-863-3033
Mailing Address - Street 1:1 E ERIE ST
Mailing Address - Street 2:SUITE 353
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2740
Mailing Address - Country:US
Mailing Address - Phone:312-863-3033
Mailing Address - Fax:312-262-4880
Practice Address - Street 1:1 E ERIE ST
Practice Address - Street 2:SUITE 353
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2740
Practice Address - Country:US
Practice Address - Phone:312-863-3033
Practice Address - Fax:312-262-4880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004821103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty