MEDICARE: DR. BRIAN FRANCIS HEATHERTON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071.006614	IL
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	071006614	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05732028	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1235152901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN FRANCIS HEATHERTON PH.D.

Provider Business Mailing Address
First Line	:	PSYCHIATRIC ASSOCIATES OF CENTRAL ILLINOIS
Second Line	:	1124 S. SIXTH STREET
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703
Country	:	US
Telephone Number	:	217-523-3143
Fax Number	:	217-523-7695

Provider Business Practice Location Address
First Line	:	PSYCHIATRIC ASSOCIATES OF CENTRAL ILLINOIS
Second Line	:	1124 S. SIXTH STREET
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703
Country	:	US
Telephone Number	:	217-523-3143
Fax Number	:	217-523-7695

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	08/09/2022

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Directions to “ DR. BRIAN FRANCIS HEATHERTON PH.D.” Practice Location

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