Provider Demographics
NPI:1053368605
Name:PSYCHOLOGY SPECIALISTS LTD
Entity type:Organization
Organization Name:PSYCHOLOGY SPECIALISTS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-428-7890
Mailing Address - Street 1:808 S ELDORADO RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6075
Mailing Address - Country:US
Mailing Address - Phone:888-428-7890
Mailing Address - Fax:
Practice Address - Street 1:808 S ELDORADO RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6075
Practice Address - Country:US
Practice Address - Phone:888-428-7890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-005747101Y00000X
IL180-005332101Y00000X
IL071-005708103TC0700X
IL071-006198103TC0700X
IL071-006980103TC0700X
IL1490111661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05732025OtherBCBS GROUP NUMBER
IL210732Medicare ID - Type UnspecifiedGROUP NUMBER