Provider Demographics
NPI:1518258904
Name:RENEE A MCARDLE PSY D & REV FRANK S MOYER P C
Entity Type:Organization
Organization Name:RENEE A MCARDLE PSY D & REV FRANK S MOYER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCARDLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:815-965-1817
Mailing Address - Street 1:4873 MANHATTAN DR
Mailing Address - Street 2:4873 MANHATTAN DRIVE
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2265
Mailing Address - Country:US
Mailing Address - Phone:815-509-6445
Mailing Address - Fax:815-965-9574
Practice Address - Street 1:4873 MANHATTAN DR
Practice Address - Street 2:4873 MANHATTAN DRIVE
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2265
Practice Address - Country:US
Practice Address - Phone:815-509-6445
Practice Address - Fax:815-965-9574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005330103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216550Medicare UPIN