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302 S Kitchell Ave Olney IL 62450-1500 | |
| (618) 392-2725 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Psychologist - Clinical |
| Location | 302 S Kitchell Ave, Olney, Illinois |
| Authorized Official Name and Position | Randall R Masterson (ASSOCIATE) |
| Authorized Official Contact | 6183922725 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
302 S Kitchell Ave Olney IL 62450-1500 Ph: (618) 392-2725 | 302 S Kitchell Ave Olney IL 62450-1500 Ph: (618) 392-2725 |
| NPI Number | 1659550879 |
|---|---|
| Provider Enumeration Date | 10/24/2007 |
| Last Update Date | 02/23/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1659550879 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 071.006994 (Illinois) | Primary |
| 103TS0200X | Psychologist - School | 969847 (Illinois) | Secondary |
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