Healthcare Provider Details

I. General information

NPI: 1578409132
Provider Name (Legal Business Name): BANNER CLINICAL & PERFORMANCE PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 N MISSION RD
PEORIA IL
61604-2343
US

IV. Provider business mailing address

2703 N MISSION RD
PEORIA IL
61604-2343
US

V. Phone/Fax

Practice location:
  • Phone: 618-554-2664
  • Fax:
Mailing address:
  • Phone: 618-554-2664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JEFFREY LAURENCE GRIMES
Title or Position: LICENSED PSYCHOLOGIST
Credential: PHD LP
Phone: 618-554-2664