1285803072 NPI number — COUNSELING FOR A CHANGE

Table of content: (NPI 1285803072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285803072 NPI number — COUNSELING FOR A CHANGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNSELING FOR A CHANGE
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:
6
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:
1285803072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 SANDY PT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOREVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62939-3122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-889-3987
Provider Business Mailing Address Fax Number:
618-351-1419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 SANDY PT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOREVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62939-3122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-889-3987
Provider Business Practice Location Address Fax Number:
618-351-1419
Provider Enumeration Date:
02/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SELOCK
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
618-889-3987

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  180006639 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180006639 . This is a "STATE LICENSE, LCPC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 11826508 . This is a "CAQH" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 03932079 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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