Provider Demographics
NPI:1245742865
Name:NEUROREHAB PSYCHOLOGY CONSULTANTS, LLC
Entity Type:Organization
Organization Name:NEUROREHAB PSYCHOLOGY CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CICCONE-COUTRE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:262-412-7302
Mailing Address - Street 1:11314 E RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-8146
Mailing Address - Country:US
Mailing Address - Phone:262-412-7302
Mailing Address - Fax:
Practice Address - Street 1:419 CENTER ST STE C
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1645
Practice Address - Country:US
Practice Address - Phone:262-412-7302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-05
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009251103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty