Provider Demographics
NPI:1144696261
Name:SPECTRUM CENTER FOR INTEGRATIVE NEUROSCIENCE PC
Entity type:Organization
Organization Name:SPECTRUM CENTER FOR INTEGRATIVE NEUROSCIENCE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:815-271-5608
Mailing Address - Street 1:4302 W CRYSTAL LAKE ROAD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4248
Mailing Address - Country:US
Mailing Address - Phone:815-271-5608
Mailing Address - Fax:779-704-2139
Practice Address - Street 1:4302 W CRYSTAL LAKE ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4248
Practice Address - Country:US
Practice Address - Phone:815-271-5608
Practice Address - Fax:779-704-2139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-009100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty