Basic Information
| Provider Information | |||||||||
| NPI: | 1033135397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLEIN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 W. CURTIS ROAD | ||||||||
| Address2: | PSYCHOLOGY | ||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173656206 | ||||||||
| FaxNumber: | 2173261234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 09/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 071005099 | IL | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 071005099 | IL | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.