Provider Demographics
NPI:1972502110
Name:MEYER, ROBERT L (PHD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:MEYER
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 1:145 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7226
Mailing Address - Country:US
Mailing Address - Phone:815-444-9999
Mailing Address - Fax:159-861-3638
Practice Address - Street 1:715 W JUDD ST
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-3186
Practice Address - Country:US
Practice Address - Phone:815-444-9999
Practice Address - Fax:815-986-1363
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1489-057103T00000X
IL071003074103T00000X
IL071-003074103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR21855Medicare UPIN