Healthcare Provider Details

I. General information

NPI: 1740407808
Provider Name (Legal Business Name): GREGORY SCOTT LAMBETH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W GREEN ST
URBANA IL
61801-3267
US

IV. Provider business mailing address

704 W DELAWARE AVE
URBANA IL
61801-4807
US

V. Phone/Fax

Practice location:
  • Phone: 217-384-3132
  • Fax:
Mailing address:
  • Phone: 217-337-6227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071005312
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: