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General NPI Number Information
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NPI Number | 1770615502
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Entity Type | Organization
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Legal Business Name | ILLINOIS STATE UNIVERSITY
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Dates
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Enumeration Date | 03/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 408 FAIRCHILD HALL CAMPUS BOX 4625
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City | NORMAL
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State | IL
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Zip | 61790
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Country | US
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Telephone | 309-438-5629
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Fax | 309-438-7476
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Provider Business Mailing Address
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Address Line | 408 FAIRCHILD HALL CAMPUS BOX 4625
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City | NORMAL
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State | IL
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Zip | 61790
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Country | US
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Telephone | 309-438-5629
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Fax | 309-438-7476
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. BRENDA JANE HUBER
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Credential | PH.D.
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Telephone | 309-438-5629
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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 | IL
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