Provider Demographics
NPI:1013472752
Name:PERIASAMY, RAJKUMAR
Entity Type:Individual
Prefix:
First Name:RAJKUMAR
Middle Name:
Last Name:PERIASAMY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:666 DUNDEE RD STE 708
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2734
Mailing Address - Country:US
Mailing Address - Phone:312-900-8642
Mailing Address - Fax:
Practice Address - Street 1:666 DUNDEE RD STE 708
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2734
Practice Address - Country:US
Practice Address - Phone:312-900-8642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010695103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty