Provider Demographics
NPI:1770592503
Name:WEBER, RICHARD PHILLIP (PSYD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:PHILLIP
Last Name:WEBER
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 1:1105 W PARK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2567
Mailing Address - Country:US
Mailing Address - Phone:847-362-5601
Mailing Address - Fax:847-362-5611
Practice Address - Street 1:1105 W PARK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2567
Practice Address - Country:US
Practice Address - Phone:847-362-5601
Practice Address - Fax:847-362-5611
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL706630Medicare ID - Type UnspecifiedPSYCHOLOGIST