Provider Demographics
NPI:1669812756
Name:AXISCARE NEUROPSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:AXISCARE NEUROPSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-284-8133
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:2580 FOXFIELD RD STE 101-4
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1403
Practice Address - Country:US
Practice Address - Phone:847-284-8133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2016-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL 8880Medicare PIN