Provider Demographics
NPI:1952504664
Name:LYNNE M. SIMON PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LYNNE M. SIMON PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-328-8779
Mailing Address - Street 1:404 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4514
Mailing Address - Country:US
Mailing Address - Phone:847-328-8779
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 619A
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4586
Practice Address - Country:US
Practice Address - Phone:847-328-8779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003423103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212655Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST