Provider Demographics
NPI:1639735137
Name:BORN, ERIC (SCHOOL PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:BORN
Suffix:
Gender:M
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-7477
Mailing Address - Country:US
Mailing Address - Phone:847-838-7109
Mailing Address - Fax:
Practice Address - Street 1:1600 EAGLE WAY
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-7477
Practice Address - Country:US
Practice Address - Phone:847-838-7109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL869241103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool