Organization
GREAT LAKES NEUROPSYCHOLOGY & COUNSELING LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHAUN A BONG PSY.D. (LICENSED CLINICAL PSYCHOLOGIST/MEMB)
(815) 231-1280
Entity
Organization
Contact information
Practice address
5758 ELAINE DR, ROCKFORD, IL 61108-3102
(815) 231-1280
(815) 231-1282
Mailing address
5758 ELAINE DR, ROCKFORD, IL 61108-3102
(815) 231-1280
(815) 231-1282
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
—
IL
103TC0700X
Clinical Psychologist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
215368
MEDICARE PTAN
IL
Enumeration date
04/09/2007
Last updated
02/05/2008
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