Provider Demographics
NPI:1316291909
Name:NEUROPSYCHOLOGY ASSESSMENT AND WELLNESS, LLC
Entity type:Organization
Organization Name:NEUROPSYCHOLOGY ASSESSMENT AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOROSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-848-1718
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:645 N MICHIGAN AVE STE 803
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5123
Practice Address - Country:US
Practice Address - Phone:312-848-1718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-04
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007239103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty