Basic Information
| Provider Information | |||||||||
| NPI: | 1669812756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AXISCARE NEUROPSYCHOLOGY, LLC | ||||||||
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| Address1: | PO BOX 2257 | ||||||||
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| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463040357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199268320 | ||||||||
| FaxNumber: | 2199263524 | ||||||||
| Practice Location | |||||||||
| Address1: | 2580 FOXFIELD RD STE 101-4 | ||||||||
| Address2: | |||||||||
| City: | ST CHARLES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601741403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472848133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2013 | ||||||||
| LastUpdateDate: | 06/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | BOWEN | ||||||||
| AuthorizedOfficialFirstName: | NEAL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8472848133 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.