Provider Demographics
NPI:1245281583
Name:PSYCHOLOGICAL SERVICES OF CENTRAL ILLINOIS, P.C.
Entity type:Organization
Organization Name:PSYCHOLOGICAL SERVICES OF CENTRAL ILLINOIS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIMOND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:217-546-3118
Mailing Address - Street 1:2921 GREENBRIAR DR
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6425
Mailing Address - Country:US
Mailing Address - Phone:217-546-3118
Mailing Address - Fax:217-546-3184
Practice Address - Street 1:2921 GREENBRIAR DR
Practice Address - Street 2:SUITE B-1
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6425
Practice Address - Country:US
Practice Address - Phone:217-546-3118
Practice Address - Fax:217-546-3184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008423762OtherHMO ILLINOIS
IL0008423762OtherBLUE CROSS-BLUE SHIELD
IL0008423762OtherHMO ILLINOIS
IL610010Medicare ID - Type UnspecifiedMEDICARE