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General NPI Number Information
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NPI Number | 1699109587
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Entity Type | Organization
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Legal Business Name | PROVIDENCE CENTER FOR PSYCHOLOGICAL SERVICES
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Dates
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Enumeration Date | 08/27/2013
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Last Update Date | 08/27/2013
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Provider Practice Location Address
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Address Line | 100 W ROOSEVELT RD # B-203
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City | WHEATON
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State | IL
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Zip | 60187-5260
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Country | US
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Telephone | 630-221-0600
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Fax | 630-221-0606
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Provider Business Mailing Address
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Address Line | 100 W ROOSEVELT RD # B-203
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City | WHEATON
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State | IL
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Zip | 60187-5260
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Country | US
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Telephone | 630-221-0600
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Fax | 630-221-0606
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Authorized Official
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Title or Position | OWNER/PSYCHOLOGIST
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Name | DR. KEENA PEEK
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Credential | PSY.D.
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Telephone | 630-221-0600
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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 | 071006625
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License Number State | IL
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