Provider Demographics
NPI:1922766526
Name:SUMMERVILLE NEUROPSYCHOLOGY CENTER PC
Entity Type:Organization
Organization Name:SUMMERVILLE NEUROPSYCHOLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-424-8900
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:
Practice Address - Street 1:2835 N SHEFFIELD AVE STE 214
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5083
Practice Address - Country:US
Practice Address - Phone:630-424-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-01
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty