Basic Information
| Provider Information | |||||||||
| NPI: | 1124424569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRAIN AND PSYCHOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4711 GOLF RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600761224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124672257 | ||||||||
| FaxNumber: | 7737512250 | ||||||||
| Practice Location | |||||||||
| Address1: | 4711 GOLF RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SKOKIE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600761224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124672257 | ||||||||
| FaxNumber: | 7737512250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2014 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | MAZUR MOSIEWICZ | ||||||||
| AuthorizedOfficialFirstName: | ANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3124672257 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071008790 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.