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General NPI Number Information
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NPI Number | 1578409132
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Entity Type | Organization
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Legal Business Name | BANNER CLINICAL & PERFORMANCE PSYCHOLOGY LLC
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Dates
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Enumeration Date | 04/27/2026
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Last Update Date | 04/27/2026
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Provider Practice Location Address
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Address Line | 2703 N MISSION RD
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City | PEORIA
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State | IL
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Zip | 61604-2343
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Country | US
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Telephone | 618-554-2664
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Fax |
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Provider Business Mailing Address
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Address Line | 2703 N MISSION RD
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City | PEORIA
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State | IL
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Zip | 61604-2343
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Country | US
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Telephone | 618-554-2664
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | JEFFREY LAURENCE GRIMES
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Credential | PHD LP
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Telephone | 618-554-2664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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