Healthcare Provider Details

I. General information

NPI: 1639452139
Provider Name (Legal Business Name): BRENT SYLVESTER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W VIRGINIA AVE
NORMAL IL
61761-3666
US

IV. Provider business mailing address

403 W VIRGINIA AVE
NORMAL IL
61761-3666
US

V. Phone/Fax

Practice location:
  • Phone: 309-268-2910
  • Fax:
Mailing address:
  • Phone: 309-268-2910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.007808
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: