Healthcare Provider Details

I. General information

NPI: 1912822024
Provider Name (Legal Business Name): CHANGE IN MIND PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N SCHUYLER AVE STE 205
KANKAKEE IL
60901-3862
US

IV. Provider business mailing address

150 N SCHUYLER AVE STE 205
KANKAKEE IL
60901-3862
US

V. Phone/Fax

Practice location:
  • Phone: 815-998-5786
  • Fax: 815-205-4493
Mailing address:
  • Phone: 815-998-5786
  • Fax: 815-205-4493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BETH A DAVISON
Title or Position: MANAGING MEMBER
Credential: CNM; PMHNP-BC
Phone: 815-998-5786