Basic Information
| Provider Information | |||||||||
| NPI: | 1275900896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACEWAY PSYCHOLOGY GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2257 | ||||||||
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| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463040357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199268320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 W SPRINGFIELD AVE STE 211 | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618204880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176216180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2015 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BLOCHER | ||||||||
| AuthorizedOfficialFirstName: | WEIMIN | ||||||||
| AuthorizedOfficialMiddleName: | GRACE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2176216180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.