Healthcare Provider Details

I. General information

NPI: 1780263384
Provider Name (Legal Business Name): CONNECTION PSYCHIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 BEECH ST BLDG 10
NORMAL IL
61761-1493
US

IV. Provider business mailing address

1100 BEECH ST BLDG 10
NORMAL IL
61761-1493
US

V. Phone/Fax

Practice location:
  • Phone: 309-463-5800
  • Fax: 833-914-2704
Mailing address:
  • Phone: 309-463-5800
  • Fax: 833-914-2704

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: MELINDA ROTH
Title or Position: OWNER
Credential: APN
Phone: 815-343-9382