=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386978161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEAL PSYCHOLOGICAL SPECIALTIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2009
-----------------------------------------------------
Last Update Date | 09/25/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 HERITAGE DR
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60014-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-477-4727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 HERITAGE DR
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60014-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | DOUGLAS N NEAL
-----------------------------------------------------
Credential | PSY.D
-----------------------------------------------------
Telephone | 814-477-4727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071004297
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------