Healthcare Provider Details

I. General information

NPI: 1194795344
Provider Name (Legal Business Name): EASTLAND PSYCHOLOGICAL SERVICES, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR EMP II, SUITE LL-1000
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

EMP II, SUITE LL-1000 1505 EASTLAND DRIVE
BLOOMINGTON IL
61701
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-1623
  • Fax:
Mailing address:
  • Phone: 309-663-1623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number71-3664
License Number StateIL

VIII. Authorized Official

Name: DR. MEL FRENCH
Title or Position: EXECUTIVE DIRECTOR
Credential: PSY.D.
Phone: 309-663-1623