NPIMap

Organization Active NPI

Waterford Counseling and Psychological Services, PC

  • Clinical Psychologist
  • Aurora, IL
National Provider Identifier
1104250067
Registry record updated Dec 15, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
071006641 Issued in IL
Legal business name
WATERFORD COUNSELING AND PSYCHOLOGICAL SERVICES, PC
Practice address
1256 Waterford Dr
Suite 140
Aurora, IL 60504-4510
Phone
(630) 898-5322
Fax
(630) 898-5324
NPI assigned
Aug 28, 2013
Last updated
Dec 15, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 15, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Gary L Coleman, PSY.D.NPI 1407994049
Title
Clinical Psychologist
Phone
(630) 898-5322

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X 180008137 IL
Professional CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YP2500X 180007319 IL
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X 071006641 IL Primary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X 149007223 IL
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X 149007369 IL

Addresses

Primary practice location

1256 Waterford Dr
Suite 140
Aurora, IL 60504-4510

Mailing address

1256 Waterford Dr
Suite 140
Aurora, IL 60504-4510
Phone (630) 898-5322

Other practice location 1

1022 Douglas Rd
Oswego, IL 60543-5133
Phone (630) 898-5322

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20131219001028 IL Part B Supplier - Clinic/Group Practice 7012144017 Receives reassigned benefits from 19 practitioners
Practice locations: Aurora, IL

National Provider Directory

National Provider Directory

Locations

1256 Waterford Dr
Ste 140
Aurora, IL 60504
Phone (630) 898-5322

1022 Douglas Rd
Oswego, IL 60543
Phone (630) 450-0022

Practitioners & affiliated clinicians

Practitioners 32

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 32

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1377648000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1702598400000",
    "number": "1104250067",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1256 WATERFORD DR",
            "address_2": "SUITE 140",
            "city": "AURORA",
            "state": "IL",
            "postal_code": "605044510",
            "telephone_number": "630-898-5322",
            "fax_number": "630-898-5324"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1256 WATERFORD DR",
            "address_2": "SUITE 140",
            "city": "AURORA",
            "state": "IL",
            "postal_code": "605044510",
            "telephone_number": "630-898-5322",
            "fax_number": "630-898-5324"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1022 Douglas Rd",
            "address_purpose": "LOCATION",
            "city": "Oswego",
            "state": "IL",
            "postal_code": "605435133",
            "country_code": "US",
            "telephone_number": "630-898-5322",
            "fax_number": "630-636-6120",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "WATERFORD COUNSELING AND PSYCHOLOGICAL SERVICES, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-08-28",
        "last_updated": "2023-12-15",
        "certification_date": "2023-12-15",
        "status": "A",
        "authorized_official_last_name": "COLEMAN",
        "authorized_official_first_name": "GARY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CLINICAL PSYCHOLOGIST",
        "authorized_official_telephone_number": "630-898-5322",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSY.D."
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "180008137",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "180007319",
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": "071006641",
            "primary": true
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "IL",
            "license": "149007223",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "IL",
            "license": "149007369",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Aurora, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.