Healthcare Provider Details

I. General information

NPI: 1326430299
Provider Name (Legal Business Name): PRAIRIE COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2422 E WASHINGTON ST SUITE 109
BLOOMINGTON IL
61704-4478
US

IV. Provider business mailing address

211 KREITZER AVE
BLOOMINGTON IL
61701-5637
US

V. Phone/Fax

Practice location:
  • Phone: 309-830-4553
  • Fax:
Mailing address:
  • Phone: 309-830-4553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003930
License Number StateIL

VIII. Authorized Official

Name: JENNIFER HAMILTON
Title or Position: OWNER
Credential: M.S. LCPC
Phone: 309-830-4553