=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215134721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUND MIND, SOUND BODY HEALTH SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2007
-----------------------------------------------------
Last Update Date | 04/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 HUNTINGTON DR N
-----------------------------------------------------
City | ALGONQUIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60102-4419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-356-5499
-----------------------------------------------------
Fax | 815-356-7139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 HUNTINGTON DR N
-----------------------------------------------------
City | ALGONQUIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60102-4419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-356-5499
-----------------------------------------------------
Fax | 815-356-7139
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. JULIE MCFAIL WEINGARZ
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 815-356-5499
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071006152
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------