Healthcare Provider Details

I. General information

NPI: 1942166608
Provider Name (Legal Business Name): THE PLAY THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2025
Last Update Date: 12/26/2025
Certification Date: 12/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 LINCOLN PLACE CT STE 406
BELLEVILLE IL
62221-5825
US

IV. Provider business mailing address

131 LINCOLN PLACE CT STE 406
BELLEVILLE IL
62221-5825
US

V. Phone/Fax

Practice location:
  • Phone: 618-631-2683
  • Fax:
Mailing address:
  • Phone: 618-631-2683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JAMES B CARROLL
Title or Position: COUNSELOR
Credential: LCPC
Phone: 618-631-2683