Healthcare Provider Details

I. General information

NPI: 1184067191
Provider Name (Legal Business Name): HEATHER O'BRIEN PSYD, HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

1801 WINDSOR RD SUITE 2617
CHAMPAIGN IL
61822-6217
US

V. Phone/Fax

Practice location:
  • Phone: 309-706-3190
  • Fax: 309-588-4115
Mailing address:
  • Phone: 217-693-6072
  • Fax: 309-588-4115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20042680A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: