Healthcare Provider Details

I. General information

NPI: 1366214611
Provider Name (Legal Business Name): STILLWATER COUNSELING AND COACHING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6912 MAIN ST STE 123
DOWNERS GROVE IL
60516-3440
US

IV. Provider business mailing address

310 MARIA CT
MINOOKA IL
60447-9359
US

V. Phone/Fax

Practice location:
  • Phone: 630-880-8903
  • Fax:
Mailing address:
  • Phone: 630-880-8903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: THERESA BURBACK
Title or Position: PARTNER
Credential: LCPC
Phone: 630-880-8903