Basic Information
| Provider Information | |||||||||
| NPI: | 1790441939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LINDBOM | ||||||||
| FirstName: | TAYLOR | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N CHESTNUT ST STE 244 | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618204872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176216180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 N CHESTNUT ST STE 244 | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618204872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176216180 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2021 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 071010651 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.