Healthcare Provider Details

I. General information

NPI: 1376303644
Provider Name (Legal Business Name): IPSATIVE PSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD # 5212
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

2501 CHATHAM RD # 5212
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 312-463-9299
  • Fax:
Mailing address:
  • Phone: 312-463-9299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERICA GOODMAN
Title or Position: OWNER
Credential: PHD
Phone: 312-463-9299