Healthcare Provider Details

I. General information

NPI: 1922326875
Provider Name (Legal Business Name): ROCK RIVER VALLEY MENTAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2010
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 WILLETT AVE
DIXON IL
61021-2348
US

IV. Provider business mailing address

PO BOX 564
DIXON IL
61021-0564
US

V. Phone/Fax

Practice location:
  • Phone: 815-284-6111
  • Fax:
Mailing address:
  • Phone: 815-284-6111
  • Fax: 815-284-6114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number071.007278
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number071.007278
License Number StateIL

VIII. Authorized Official

Name: DR. CAROLYN SUE VAN DOREN
Title or Position: DIRECTOR
Credential: PSY. D.
Phone: 815-284-6111