| Lifestance Health | |
|
808 S Eldorado Rd Ste 102 Bloomington IL 61704-6075 | |
| (888) 428-7890 | |
| Not Available |
| Full Name | Lifestance Health |
|---|---|
| Speciality | Psychologist |
| Location | 808 S Eldorado Rd Ste 102, Bloomington, Illinois |
| Authorized Official Name and Position | Adam Russo (VP OF OPERATIONS) |
| Authorized Official Contact | 8884287890 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lifestance Health 808 S Eldorado Rd Ste 102 Bloomington IL 61704-6075 Ph: (888) 428-7890 | Lifestance Health 808 S Eldorado Rd Ste 102 Bloomington IL 61704-6075 Ph: (888) 428-7890 |
| NPI Number | 1053368605 |
|---|---|
| Provider Enumeration Date | 05/28/2006 |
| Last Update Date | 09/26/2022 |
| Certification Date | 09/26/2022 |
| Medicare PECOS PAC ID | 9739152380 |
|---|---|
| Medicare Enrollment ID | O20050112000476 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053368605 | NPI | - | NPPES |
| Provider Name | Seth Hatlelid |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1447270368 PECOS PAC ID: 4688682545 Enrollment ID: I20060404000334 |
| Provider Name | Nicole D Noble |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1700052818 PECOS PAC ID: 8224106109 Enrollment ID: I20081006000071 |
| Provider Name | Leroy R Hall |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1942318837 PECOS PAC ID: 5395882658 Enrollment ID: I20091020000268 |
| Provider Name | Ann Christine Crumpler |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1629209432 PECOS PAC ID: 3072650134 Enrollment ID: I20091021000573 |
| Provider Name | Regina Brian |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1699848051 PECOS PAC ID: 4981883758 Enrollment ID: I20110125001242 |
| Provider Name | Blair M Brown |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1215377510 PECOS PAC ID: 7719112549 Enrollment ID: I20131031001645 |
| Provider Name | Heather Obrien |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1184067191 PECOS PAC ID: 7911133343 Enrollment ID: I20131113001312 |
| Provider Name | Jie Jiao |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1053720284 PECOS PAC ID: 9032330329 Enrollment ID: I20141030001566 |
| Provider Name | Michael R Knobeloch |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1619396736 PECOS PAC ID: 2567771827 Enrollment ID: I20151027003117 |
| Provider Name | Neil A Jepson |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1689687709 PECOS PAC ID: 1951362789 Enrollment ID: I20160418001117 |
| Provider Name | Sarah E Cain |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1780969816 PECOS PAC ID: 4981993672 Enrollment ID: I20160519001368 |
| Provider Name | Cheryl Renee Carter |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1467902130 PECOS PAC ID: 0648568048 Enrollment ID: I20161018002890 |
| Provider Name | Michele M Carroll |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1588008122 PECOS PAC ID: 0749547115 Enrollment ID: I20171121000409 |
| Provider Name | Alexander Willett |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1710493770 PECOS PAC ID: 2062771041 Enrollment ID: I20180119001905 |
| Provider Name | Lisa J Brandyberry |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1760499156 PECOS PAC ID: 9537136627 Enrollment ID: I20190125000869 |
| Provider Name | Dynesha D Mason-grissom |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1043789688 PECOS PAC ID: 8921432840 Enrollment ID: I20200102000505 |
| Provider Name | Jessica M Fino |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1427519156 PECOS PAC ID: 4789010067 Enrollment ID: I20200205000128 |
| Provider Name | Ara Joann Rose Holiday |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1649762667 PECOS PAC ID: 8123376860 Enrollment ID: I20210203000775 |
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