Provider Demographics
NPI:1992051130
Name:NEUROBEHAVIORAL GROUP PC
Entity type:Organization
Organization Name:NEUROBEHAVIORAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-972-4248
Mailing Address - Street 1:1755 PARK ST
Mailing Address - Street 2:#200
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-4861
Mailing Address - Country:US
Mailing Address - Phone:630-449-4270
Mailing Address - Fax:630-820-2358
Practice Address - Street 1:1755 PARK ST
Practice Address - Street 2:#200
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-4861
Practice Address - Country:US
Practice Address - Phone:630-449-4270
Practice Address - Fax:630-820-2358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007744103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8063OtherPTAN