Healthcare Provider Details

I. General information

NPI: 1467935775
Provider Name (Legal Business Name): KELLY SUE WILLENBORG MA IN GERONTOLOGY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SUR WOODS DR
EFFINGHAM IL
62401-3113
US

IV. Provider business mailing address

604 E JEFFERSON AVE
EFFINGHAM IL
62401-3405
US

V. Phone/Fax

Practice location:
  • Phone: 217-254-2149
  • Fax:
Mailing address:
  • Phone: 217-254-2149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: