1639688724 NPI number — NOVA M. GRIFFITH, PH.D., PSYCHOLOGICAL SERVICES LLC

Table of content: (NPI 1639688724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639688724 NPI number — NOVA M. GRIFFITH, PH.D., PSYCHOLOGICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOVA M. GRIFFITH, PH.D., PSYCHOLOGICAL SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639688724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 E 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTON CITY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62951-1539
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-696-2922
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 N 13TH ST STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERRIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62948-3255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-969-2922
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFITH
Authorized Official First Name:
NOVA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER,LIC. CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
618-969-2922

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071007669 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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