Healthcare Provider Details

I. General information

NPI: 1427021393
Provider Name (Legal Business Name): PEORIA PSYCHOLOGICAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 N FAIRMONT DR
PEORIA IL
61614-4246
US

IV. Provider business mailing address

5505 N FAIRMONT DR
PEORIA IL
61614-4246
US

V. Phone/Fax

Practice location:
  • Phone: 309-689-6700
  • Fax: 309-689-0774
Mailing address:
  • Phone: 309-689-6700
  • Fax: 309-689-0774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number14987
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005320
License Number StateIL

VIII. Authorized Official

Name: DR. JANE VELEZ
Title or Position: OWNER, CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 309-689-6700