Healthcare Provider Details

I. General information

NPI: 1639250848
Provider Name (Legal Business Name): LINDA S CULTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W PARK STREET
CHAMPAIGN IL
61820-3929
US

IV. Provider business mailing address

1801 FOX DR
CHAMPAIGN IL
61820-7236
US

V. Phone/Fax

Practice location:
  • Phone: 217-373-2430
  • Fax: 217-373-2443
Mailing address:
  • Phone: 217-373-2430
  • Fax: 217-373-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-010836
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: