Individual
MR. RANDALL WARREN SUMMERVILLE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PSYD
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
071-006658
IL
103TA0700X
Adult Development & Aging Psychologist
071-006658
IL
103TC0700X
Clinical Psychologist
Primary
071-006658
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
02233000
BCBS OF IL GROUP PROVIDER
IL
01
—
071-0006658
PROFESSIONAL LICENSE
IL
Enumeration date
09/28/2006
Last updated
12/05/2022
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