1619118304 NPI number — MARTIN LUTHER KING JR. COMMUNITY SERVICE AREA PROJECT

Table of content: SANDRA J TOBIN MA, LMHC, LSW, CEAP (NPI 1851314645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619118304 NPI number — MARTIN LUTHER KING JR. COMMUNITY SERVICE AREA PROJECT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN LUTHER KING JR. COMMUNITY SERVICE AREA PROJECT
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:
1619118304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 N COURT ST STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61103-6898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-233-9915
Provider Business Mailing Address Fax Number:
815-962-2180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 N COURT ST STE 204
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:
61103-6898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-233-9915
Provider Business Practice Location Address Fax Number:
815-962-2180
Provider Enumeration Date:
03/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
COLLINS
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
W
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
815-233-9915

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  08002 , 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)





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