Healthcare Provider Details

I. General information

NPI: 1376779025
Provider Name (Legal Business Name): CONSTANCE D OWENS-MOONEY LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

IV. Provider business mailing address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

V. Phone/Fax

Practice location:
  • Phone: 309-820-3735
  • Fax: 309-820-3745
Mailing address:
  • Phone: 309-820-3735
  • Fax: 309-820-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.007072
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.007072
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.007072
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: