Healthcare Provider Details

I. General information

NPI: 1851526933
Provider Name (Legal Business Name): CENTER FOR NEUROPSYCHIATRIC DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N HAMMES AVE SUITE 205
JOLIET IL
60435-6680
US

IV. Provider business mailing address

210 N HAMMES AVE SUITE 205
JOLIET IL
60435-6680
US

V. Phone/Fax

Practice location:
  • Phone: 815-729-7790
  • Fax: 815-725-8144
Mailing address:
  • Phone: 815-729-7790
  • Fax: 815-725-8144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178005617
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036072698
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036082815
License Number StateIL

VIII. Authorized Official

Name: DIANE L TIPPY
Title or Position: BILLING ADMINISTRATOR
Credential:
Phone: 815-729-7790