Healthcare Provider Details

I. General information

NPI: 1457214595
Provider Name (Legal Business Name): BRIANA ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 N MATTIS AVE STE 116
CHAMPAIGN IL
61821-7900
US

IV. Provider business mailing address

313 N MATTIS AVE STE 116
CHAMPAIGN IL
61821-7900
US

V. Phone/Fax

Practice location:
  • Phone: 224-232-8057
  • Fax: 217-888-2744
Mailing address:
  • Phone: 224-232-8057
  • Fax: 217-888-2744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178022056
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: