Healthcare Provider Details

I. General information

NPI: 1407825110
Provider Name (Legal Business Name): MAUREEN PATRICIA TWEEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2804 WOODRIDGE RD
CHAMPAIGN IL
61822-7550
US

IV. Provider business mailing address

2804 WOODRIDGE RD
CHAMPAIGN IL
61822-7550
US

V. Phone/Fax

Practice location:
  • Phone: 972-979-5027
  • Fax:
Mailing address:
  • Phone: 972-979-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042433A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1113355
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: