Healthcare Provider Details

I. General information

NPI: 1417575853
Provider Name (Legal Business Name): JOSEPH BABIONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

IV. Provider business mailing address

5409 N KNOXVILLE AVE STE 100
PEORIA IL
61614-5069
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone: 309-689-6008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.010307
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: