Healthcare Provider Details

I. General information

NPI: 1306078894
Provider Name (Legal Business Name): PROFESSIONAL SERVICES IN HEALTH PSYCHOLOGY, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 BETHANY RD
SYCAMORE IL
60178-3124
US

IV. Provider business mailing address

PO BOX 276
SYCAMORE IL
60178-0276
US

V. Phone/Fax

Practice location:
  • Phone: 779-777-7335
  • Fax: 815-758-8441
Mailing address:
  • Phone: 815-758-8400
  • Fax: 815-758-8441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. BEN MATHIAS BROWER
Title or Position: BUSINESS MANAGER
Credential: MBA
Phone: 815-758-8400