Healthcare Provider Details

I. General information

NPI: 1518258904
Provider Name (Legal Business Name): RENEE A MCARDLE PSY D & REV FRANK S MOYER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4873 MANHATTAN DR 4873 MANHATTAN DRIVE
ROCKFORD IL
61108-2265
US

IV. Provider business mailing address

4873 MANHATTAN DR 4873 MANHATTAN DRIVE
ROCKFORD IL
61108-2265
US

V. Phone/Fax

Practice location:
  • Phone: 815-509-6445
  • Fax: 815-965-9574
Mailing address:
  • Phone: 815-509-6445
  • Fax: 815-965-9574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005330
License Number StateIL

VIII. Authorized Official

Name: MRS. RENEE A MCARDLE
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSY. D.
Phone: 815-965-1817