Provider Demographics
NPI:1790117208
Name:ILLINOIS NEUROTHERAPY ASSOCIATES
Entity Type:Organization
Organization Name:ILLINOIS NEUROTHERAPY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:630-210-4863
Mailing Address - Street 1:6800 MAIN ST
Mailing Address - Street 2:STE 210
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-3493
Mailing Address - Country:US
Mailing Address - Phone:630-210-4863
Mailing Address - Fax:
Practice Address - Street 1:6800 MAIN ST
Practice Address - Street 2:STE 210
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-3493
Practice Address - Country:US
Practice Address - Phone:630-210-4863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490120621041C0700X
IL038010254111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty