Provider Demographics
NPI:1003425786
Name:WEIDEN, BRYCIE (PSYD)
Entity type:Individual
Prefix:
First Name:BRYCIE
Middle Name:
Last Name:WEIDEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 MIROMAR LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-4021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 NE GLEN OAK AVE STE 101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3167
Practice Address - Country:US
Practice Address - Phone:309-655-7378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010436103TC0700X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical