Provider Demographics
NPI:1396856134
Name:PSYCHOLOGICAL RESOURCE CENTER PC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL RESOURCE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:BORNSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-461-2333
Mailing Address - Street 1:46 CUMBERLAND DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLNSHIRE
Mailing Address - State:IL
Mailing Address - Zip Code:60069
Mailing Address - Country:US
Mailing Address - Phone:708-461-2333
Mailing Address - Fax:847-267-8015
Practice Address - Street 1:175 OLDE HALF DAY RD
Practice Address - Street 2:SUITE 140-2
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-3061
Practice Address - Country:US
Practice Address - Phone:708-461-2333
Practice Address - Fax:773-751-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004534103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4932021OtherBLUE CROSS BLUE SHIELD
200503Medicare ID - Type Unspecified
203373Medicare ID - Type Unspecified