Healthcare Provider Details

I. General information

NPI: 1144333485
Provider Name (Legal Business Name): EUGENE D VACCARO PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 E QUEENWOOD RD
MORTON IL
61550-2985
US

IV. Provider business mailing address

4603 S KING ARTHUR CT
MAPLETON IL
61547-9549
US

V. Phone/Fax

Practice location:
  • Phone: 309-263-5565
  • Fax: 309-263-9336
Mailing address:
  • Phone: 309-263-5565
  • Fax: 309-263-9336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: