Provider Demographics
NPI:1619119450
Name:VERONA, EDELYN (PHD)
Entity Type:Individual
Prefix:
First Name:EDELYN
Middle Name:
Last Name:VERONA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E GREEN ST FL 3
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5762
Mailing Address - Country:US
Mailing Address - Phone:217-333-0041
Mailing Address - Fax:217-333-0064
Practice Address - Street 1:505 E GREEN ST
Practice Address - Street 2:SUITE 329
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-5723
Practice Address - Country:US
Practice Address - Phone:217-333-0041
Practice Address - Fax:217-333-0064
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71007346103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical