Healthcare Provider Details

I. General information

NPI: 1912266297
Provider Name (Legal Business Name): BRYAN MANION, LIFE COACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N RANDOLPH ST
CHAMPAIGN IL
61820-3949
US

IV. Provider business mailing address

PO BOX 934
CHAMPAIGN IL
61824-0934
US

V. Phone/Fax

Practice location:
  • Phone: 217-474-8455
  • Fax:
Mailing address:
  • Phone: 217-474-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.006836
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.006836
License Number StateIL

VIII. Authorized Official

Name: MR. BRYAN MYLES MANION
Title or Position: OWNER
Credential:
Phone: 217-474-8455