=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205507407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENTAL HEALTH PARTNERSHIP LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2021
-----------------------------------------------------
Last Update Date | 09/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 BETHANY RD
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-403-9463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1625 BETHANY RD
-----------------------------------------------------
City | SYCAMORE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60178-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-403-9463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. ERICA MARIE VEACH
-----------------------------------------------------
Credential | PSY.D
-----------------------------------------------------
Telephone | 815-403-9463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------