Provider Demographics
NPI:1598722779
Name:SIMON, LYNNE MARTIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYNNE
Middle Name:MARTIN
Last Name:SIMON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4514
Mailing Address - Country:US
Mailing Address - Phone:847-328-8779
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:619A
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4586
Practice Address - Country:US
Practice Address - Phone:847-328-8779
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212655Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER