Healthcare Provider Details

I. General information

NPI: 1124731484
Provider Name (Legal Business Name): LIFELONG ACCESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE STE L500
NORMAL IL
61761-3551
US

IV. Provider business mailing address

2000 JACOBSSEN DR
NORMAL IL
61761-6277
US

V. Phone/Fax

Practice location:
  • Phone: 309-452-0069
  • Fax:
Mailing address:
  • Phone: 309-451-8888
  • Fax: 309-451-8989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PATRICK DYCE BAILEY
Title or Position: PROGRAM SUPPORTS SPECIALIST
Credential:
Phone: 309-451-8888