Healthcare Provider Details

I. General information

NPI: 1114135324
Provider Name (Legal Business Name): RACHEL MCCULLOUGH MATTHEWS D.MIN., LPC, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 HAMILTON DR
CHAMPAIGN IL
61820-6812
US

IV. Provider business mailing address

708 HAMILTON DR
CHAMPAIGN IL
61820-6812
US

V. Phone/Fax

Practice location:
  • Phone: 864-275-2495
  • Fax:
Mailing address:
  • Phone: 864-275-2495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.012879
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLPCI #4985
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberASSOCIATE #66
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLPC 5356
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC 5356
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: