Provider Demographics
NPI:1770615502
Name:ILLINOIS STATE UNIVERSITY
Entity type:Organization
Organization Name:ILLINOIS STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:HUBER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:309-438-5629
Mailing Address - Street 1:408 FAIRCHILD HALL
Mailing Address - Street 2:CAMPUS BOX 4625
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790
Mailing Address - Country:US
Mailing Address - Phone:309-438-5629
Mailing Address - Fax:309-438-7476
Practice Address - Street 1:408 FAIRCHILD HALL
Practice Address - Street 2:CAMPUS BOX 4625
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790
Practice Address - Country:US
Practice Address - Phone:309-438-5629
Practice Address - Fax:309-438-7476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty