Provider Demographics
NPI:1821151135
Name:COUNSELING AND DIAGNOSTIC CENTER OF WOODFIELD, LTD.
Entity Type:Organization
Organization Name:COUNSELING AND DIAGNOSTIC CENTER OF WOODFIELD, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:JEZL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-884-0210
Mailing Address - Street 1:1325 WILEY ROAD
Mailing Address - Street 2:SUITE 165
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173
Mailing Address - Country:US
Mailing Address - Phone:847-884-0210
Mailing Address - Fax:847-884-7349
Practice Address - Street 1:1325 WILEY ROAD
Practice Address - Street 2:SUITE 165
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173
Practice Address - Country:US
Practice Address - Phone:847-884-0210
Practice Address - Fax:847-884-7349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213116Medicare ID - Type Unspecified