Provider Demographics
NPI:1104250067
Name:WATERFORD COUNSELING AND PSYCHOLOGICAL SERVICES, PC
Entity type:Organization
Organization Name:WATERFORD COUNSELING AND PSYCHOLOGICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-898-5322
Mailing Address - Street 1:1256 WATERFORD DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4510
Mailing Address - Country:US
Mailing Address - Phone:630-898-5322
Mailing Address - Fax:630-898-5324
Practice Address - Street 1:1256 WATERFORD DR
Practice Address - Street 2:SUITE 140
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4510
Practice Address - Country:US
Practice Address - Phone:630-898-5322
Practice Address - Fax:630-898-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008137101YP2500X
IL180007319101YP2500X
103T00000X, 103TC0700X
IL1490072231041C0700X
IL1490073691041C0700X
IL071006641103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty