Provider Demographics
NPI:1073609426
Name:VIGGIANO, JAMES M (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:VIGGIANO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6975 REDANSA DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-1201
Mailing Address - Country:US
Mailing Address - Phone:815-398-7000
Mailing Address - Fax:815-398-0671
Practice Address - Street 1:6975 REDANSA DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1201
Practice Address - Country:US
Practice Address - Phone:815-398-7000
Practice Address - Fax:815-398-0671
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004266103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL-4874Medicare PIN