=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497082770
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY PSYCHIATRY AND COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2009
-----------------------------------------------------
Last Update Date | 11/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 MARKET ST SUITE 14
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-5093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-697-6290
-----------------------------------------------------
Fax | 847-697-0252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 MARKET ST SUITE 14
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-5093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-697-6290
-----------------------------------------------------
Fax | 847-697-0252
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. SYED WALIUDDIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-697-6290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 036-119726
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 036-119726
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------