Provider Demographics
NPI:1275900896
Name:GRACEWAY PSYCHOLOGY GROUP, LLC
Entity Type:Organization
Organization Name:GRACEWAY PSYCHOLOGY GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WEIMIN
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:BLOCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:217-621-6180
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:
Practice Address - Street 1:201 W SPRINGFIELD AVE STE 211
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4880
Practice Address - Country:US
Practice Address - Phone:217-621-6180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty