MEDICARE: RIVERSIDE COUNSELING CENTER PLLC

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	1041C0700X	Clinical Social Worker
2	101Y00000X	Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952879546
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE COUNSELING CENTER PLLC

Provider Business Mailing Address
First Line	:	6653 WEAVER RD STE 112
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61114-8052
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6653 WEAVER RD STE 112
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61114-8052
Country	:	US
Telephone Number	:	815-201-2687
Fax Number	:

Authorized Official
Title or Position	:	CONTRACTING
Name	:	KIRSTEN EKBERG
Credential	:
Telephone Number	:	815-299-1955

Provider Enumeration Date	:	11/13/2018
Last Update Date	:	12/22/2020

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