Healthcare Provider Details

I. General information

NPI: 1821358987
Provider Name (Legal Business Name): THOMAS LLOYD SLATTERY PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
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

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

V. Phone/Fax

Practice location:
  • Phone: 309-310-4636
  • Fax: 309-588-4115
Mailing address:
  • Phone: 309-310-4636
  • Fax: 309-588-4115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071008362
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: