Provider Demographics
NPI:1578598462
Name:HARLEY, J. PRESTON (PHD)
Entity Type:Individual
Prefix:DR
First Name:J. PRESTON
Middle Name:
Last Name:HARLEY
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:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-0492
Mailing Address - Country:US
Mailing Address - Phone:630-293-4321
Mailing Address - Fax:630-293-4297
Practice Address - Street 1:3155 BOOK RD
Practice Address - Street 2:SUITE 103
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-9545
Practice Address - Country:US
Practice Address - Phone:630-293-4321
Practice Address - Fax:630-293-4297
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004240103G00000X, 103TC0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR78420Medicare UPIN
IL628310Medicare ID - Type Unspecified