=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053711127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY PSYCHOLOGICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2014
-----------------------------------------------------
Last Update Date | 04/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 456 W FRONTAGE RD ROOM 32
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-387-0790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 456 W FRONTAGE RD STE 232
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60093-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-387-0790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH W. BYRNE
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 847-644-1210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071008414
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------