Healthcare Provider Details

I. General information

NPI: 1770824450
Provider Name (Legal Business Name): MS. LORRAINE MALTBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
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

291 IL ROUTE 2 #48
DIXON IL
61021-9182
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-6611
  • Fax:
Mailing address:
  • Phone: 386-264-9457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: