Healthcare Provider Details

I. General information

NPI: 1861538779
Provider Name (Legal Business Name): PHILLIP ARTHUR FOSTER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S ELDORADO RD STE 102
BLOOMINGTON IL
61704-6071
US

IV. Provider business mailing address

808 ELDORADO SUITE 102
BLOOMINGTON IL
61704
US

V. Phone/Fax

Practice location:
  • Phone: 309-706-3190
  • Fax: 309-588-4115
Mailing address:
  • Phone: 309-706-3190
  • Fax: 309-588-4115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180000680
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071007538
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: