Healthcare Provider Details

I. General information

NPI: 1356451009
Provider Name (Legal Business Name): CENTER FOR RURAL PSYCHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W PIERCE ST
ELBURN IL
60119-8201
US

IV. Provider business mailing address

PO BOX 8071
ELBURN IL
60119-8071
US

V. Phone/Fax

Practice location:
  • Phone: 630-365-0899
  • Fax: 630-365-9150
Mailing address:
  • Phone: 630-365-0899
  • Fax: 630-365-9150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL WILLIAM MANGIS
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 630-365-0899