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General NPI Number Information
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NPI Number | 1053368605
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGY SPECIALISTS LTD
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Dates
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Enumeration Date | 05/28/2006
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Last Update Date | 09/26/2022
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Provider Practice Location Address
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Address Line | 808 S ELDORADO RD STE 102
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City | BLOOMINGTON
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State | IL
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Zip | 61704-6075
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Country | US
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Telephone | 888-428-7890
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Fax |
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Provider Business Mailing Address
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Address Line | 808 S ELDORADO RD STE 102
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City | BLOOMINGTON
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State | IL
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Zip | 61704-6075
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Country | US
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Telephone | 888-428-7890
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Fax |
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Authorized Official
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Title or Position | VP OF OPERATIONS
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Name | ADAM RUSSO
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Credential |
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Telephone | 888-428-7890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 180-005747
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 180-005332
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071-005708
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071-006980
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License Number State | IL
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Taxonomy #5
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149011166
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License Number State | IL
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Taxonomy #6
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071-006198
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License Number State | IL
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