Provider Demographics
NPI:1366558553
Name:MIDAMERICAN PSYCHOLOGICAL INSTITUTE PC
Entity type:Organization
Organization Name:MIDAMERICAN PSYCHOLOGICAL INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD BCBA
Authorized Official - Phone:815-735-0732
Mailing Address - Street 1:1415 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-1442
Mailing Address - Country:US
Mailing Address - Phone:815-735-0732
Mailing Address - Fax:815-722-7310
Practice Address - Street 1:1415 MAPLE RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-1442
Practice Address - Country:US
Practice Address - Phone:815-735-0732
Practice Address - Fax:815-722-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006470103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932152OtherBCBS GROUP NUMBER
IL209886Medicare ID - Type Unspecified