MEDICARE: EAST PEORIA COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1447931779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST PEORIA COUNSELING LLC

Provider Business Mailing Address
First Line	:	106 SMILEY CT
Second Line	:
City	:	WASHINGTON
State	:	IL
Zip	:	61571-1034
Country	:	US
Telephone Number	:	309-339-5291
Fax Number	:

Provider Business Practice Location Address
First Line	:	252 E WASHINGTON ST STE D
Second Line	:
City	:	EAST PEORIA
State	:	IL
Zip	:	61611-2563
Country	:	US
Telephone Number	:	331-871-0280
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST/OWNER
Name	:	MR. KYLE LANE PEARSON
Credential	:	LCPC NCC CADC
Telephone Number	:	309-339-5291

Provider Enumeration Date	:	07/28/2023
Last Update Date	:	04/22/2025

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