Provider Demographics
NPI:1821180803
Name:SUMMERVILLE, RANDALL WARREN (PSYD)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:WARREN
Last Name:SUMMERVILLE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 E BUTTERFIELD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4880
Mailing Address - Country:US
Mailing Address - Phone:630-424-8900
Mailing Address - Fax:630-424-9017
Practice Address - Street 1:477 E BUTTERFIELD RD STE 102
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4880
Practice Address - Country:US
Practice Address - Phone:630-424-8900
Practice Address - Fax:630-424-9017
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006658103G00000X, 103TA0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02233000OtherBCBS OF IL GROUP PROVIDER
IL071-0006658OtherPROFESSIONAL LICENSE
ILK18177Medicare UPIN