1497002679 NPI number — BRIAN JERALD MUELLER LPC

Table of content: BRIAN JERALD MUELLER LPC (NPI 1497002679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497002679 NPI number — BRIAN JERALD MUELLER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUELLER
Provider First Name:
BRIAN
Provider Middle Name:
JERALD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
M

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:
1497002679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
232 MCMILLAN CT
Provider Second Line Business Mailing Address:
APT. 201
Provider Business Mailing Address City Name:
CORTLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60112-4169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-299-2560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8616 NORTHERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61107-5309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-979-3402
Provider Business Practice Location Address Fax Number:
815-332-6090
Provider Enumeration Date:
08/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  178.007967 , 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: 1497002679 . This is a "NATIONAL PROVIDER IDENTIFIER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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