Healthcare Provider Details

I. General information

NPI: 1801409974
Provider Name (Legal Business Name): MINDFUL PSYCHIATRIC SERVICES, MDSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 N DIVISION ST STE 509
MORRIS IL
60450-3107
US

IV. Provider business mailing address

1802 N DIVISION ST STE 509
MORRIS IL
60450-3107
US

V. Phone/Fax

Practice location:
  • Phone: 815-941-3882
  • Fax: 815-941-3884
Mailing address:
  • Phone: 815-941-3882
  • Fax: 815-941-3884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES DYERS
Title or Position: PRESIDENT
Credential: DO
Phone: 815-941-3882