Provider Demographics
NPI:1174749881
Name:SPRINGFIELD PSYCHOLOGICAL CENTER, LLC
Entity type:Organization
Organization Name:SPRINGFIELD PSYCHOLOGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:FISHER
Authorized Official - Last Name:PAONI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:217-793-3949
Mailing Address - Street 1:2325 W WHITE OAKS DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7419
Mailing Address - Country:US
Mailing Address - Phone:217-793-3949
Mailing Address - Fax:217-793-3995
Practice Address - Street 1:2325 W WHITE OAKS DR
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7419
Practice Address - Country:US
Practice Address - Phone:217-793-3949
Practice Address - Fax:217-793-3995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003515103TC0700X
IL071002838103TC0700X
IL071005516103TC0700X
IL1490084761041C0700X
IL071006429103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty