Provider Demographics
NPI:1952378192
Name:PSYCHOLOGICAL ASSOCIATES PROFESSIONALS LLC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL ASSOCIATES PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:ED D
Authorized Official - Phone:309-691-0420
Mailing Address - Street 1:5409 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-691-0420
Mailing Address - Fax:309-691-0520
Practice Address - Street 1:5409 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-691-0420
Practice Address - Fax:309-691-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL71002085103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
07220997OtherBCBS
L015956OtherCHAMPUS
IL209355Medicare ID - Type Unspecified
IL205026Medicare ID - Type Unspecified