Provider Demographics
NPI:1477855328
Name:ENVISION PSYCHOLOGICAL SERVICES, P.C.
Entity Type:Organization
Organization Name:ENVISION PSYCHOLOGICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STASEK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:815-388-9071
Mailing Address - Street 1:3221 MIDLANE DR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9457
Mailing Address - Country:US
Mailing Address - Phone:815-388-9071
Mailing Address - Fax:847-516-2510
Practice Address - Street 1:1100 COUGAR TRL
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-6057
Practice Address - Country:US
Practice Address - Phone:815-388-9071
Practice Address - Fax:847-516-2510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005965103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty