Basic Information
| Provider Information | |||||||||
| NPI: | 1780263384 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONNECTION PSYCHIATRY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 BEECH ST BLDG 10 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617611493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094635800 | ||||||||
| FaxNumber: | 8339142704 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 BEECH ST BLDG 10 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617611493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3094635800 | ||||||||
| FaxNumber: | 8339142704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2021 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | MELINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8153439382 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APN | ||||||||
| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.