Provider Demographics
NPI:1609043553
Name:VICTORSON, DAVID EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWARD
Last Name:VICTORSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:EVANSTON HOSPITAL
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-1206
Mailing Address - Fax:847-570-1248
Practice Address - Street 1:2400 CHESTNUT AVE
Practice Address - Street 2:GLENVIEW PARK CENTER - INTEGRATIVE MEDICINE, SUITE A
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-8321
Practice Address - Country:US
Practice Address - Phone:847-657-3540
Practice Address - Fax:847-657-3530
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL071-007103103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071007103OtherIL STATE LIC