Provider Demographics
NPI:1275946048
Name:CHICAGOLAND NEUROPSYCHOLOGY LLC
Entity Type:Organization
Organization Name:CHICAGOLAND NEUROPSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIETZKE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-931-3439
Mailing Address - Street 1:101 N MARION ST
Mailing Address - Street 2:STE. 313
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1167
Mailing Address - Country:US
Mailing Address - Phone:773-931-3439
Mailing Address - Fax:
Practice Address - Street 1:101 N MARION ST
Practice Address - Street 2:STE 313
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1167
Practice Address - Country:US
Practice Address - Phone:773-931-3439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008376103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty