1902916976 NPI number — CROSSROADS COMMUNITY COUNSELING

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902916976 NPI number — CROSSROADS COMMUNITY COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSROADS COMMUNITY COUNSELING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902916976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 QUINCY AVE
Provider Second Line Business Mailing Address:
SUITE 31
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60540-3955
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-428-1056
Provider Business Mailing Address Fax Number:
630-428-1167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 QUINCY AVE
Provider Second Line Business Practice Location Address:
SUITE 31
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60540-3955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-428-1056
Provider Business Practice Location Address Fax Number:
630-428-1167
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MURPHY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PASTOR
Authorized Official Telephone Number:
630-428-1056

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0002227811 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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