Provider Demographics
NPI:1780263384
Name:CONNECTION PSYCHIATRY, PLLC
Entity type:Organization
Organization Name:CONNECTION PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:815-343-9382
Mailing Address - Street 1:1100 BEECH ST BLDG 10
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1493
Mailing Address - Country:US
Mailing Address - Phone:309-463-5800
Mailing Address - Fax:833-914-2704
Practice Address - Street 1:1100 BEECH ST BLDG 10
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-1493
Practice Address - Country:US
Practice Address - Phone:309-463-5800
Practice Address - Fax:833-914-2704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty