=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376303644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IPSATIVE PSYCHOLOGY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2024
-----------------------------------------------------
Last Update Date | 03/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 CHATHAM RD # 5212
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62704-4188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-463-9299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 CHATHAM RD # 5212
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62704-4188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-463-9299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERICA GOODMAN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 312-463-9299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------