Provider Demographics
NPI:1972990497
Name:ICON PSYCHOLOGIES CORP
Entity Type:Organization
Organization Name:ICON PSYCHOLOGIES CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SOBEREKON
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-342-6066
Mailing Address - Street 1:620 N RIVER RD STE 106
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8951
Mailing Address - Country:US
Mailing Address - Phone:630-364-2484
Mailing Address - Fax:630-536-8511
Practice Address - Street 1:620 N RIVER RD STE 106
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8951
Practice Address - Country:US
Practice Address - Phone:630-364-2484
Practice Address - Fax:630-536-8511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2017-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty