1629787239 NPI number — YMG PSYCHOLOGICAL SERVICES, PLLC

Table of content: MS. HILARY SOMERS VICTOROFF FNP (NPI 1447310388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629787239 NPI number — YMG PSYCHOLOGICAL SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YMG PSYCHOLOGICAL SERVICES, PLLC
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:
1629787239
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
306 W GRAHAM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVOY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61874-9441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-278-0159
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 DEVONSHIRE DR. BLD. C SUITE 132
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-278-0159
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2022

Additional Information

Authorized Official

Authorized Official Last Name:
MASON GRISSOM
Authorized Official First Name:
DYNESHA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER/PSYCHOLOGIST
Authorized Official Telephone Number:
217-278-0159

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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