Healthcare Provider Details

I. General information

NPI: 1013057868
Provider Name (Legal Business Name): LEIGH TERRELL LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 IL ROUTE 2
DIXON IL
61021-9118
US

IV. Provider business mailing address

109 COLLEGE AVE
PROPHETSTOWN IL
61277-1029
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-6611
  • Fax: 815-284-6598
Mailing address:
  • Phone: 815-631-6932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: