Healthcare Provider Details

I. General information

NPI: 1902928005
Provider Name (Legal Business Name): COLLABORATIVE SOLUTIONS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W FRONT ST SUITE 400A
BLOOMINGTON IL
61701-5048
US

IV. Provider business mailing address

200 W FRONT ST SUITE 400A
BLOOMINGTON IL
61701-5048
US

V. Phone/Fax

Practice location:
  • Phone: 309-828-2860
  • Fax: 309-827-2637
Mailing address:
  • Phone: 309-828-2860
  • Fax: 309-827-2637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. CHERYL L GAINES
Title or Position: CEOPRESIDENT
Credential: LCPC
Phone: 309-828-2860