Healthcare Provider Details

I. General information

NPI: 1821457904
Provider Name (Legal Business Name): AMBER GALLAHER-KOCH MS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 E 2ND ST
BEARDSTOWN IL
62618-1263
US

IV. Provider business mailing address

121 E 2ND ST
BEARDSTOWN IL
62618-1263
US

V. Phone/Fax

Practice location:
  • Phone: 217-323-2980
  • Fax: 217-323-3731
Mailing address:
  • Phone: 217-323-2980
  • Fax: 217-323-3731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.011544
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: