Healthcare Provider Details

I. General information

NPI: 1700342532
Provider Name (Legal Business Name): STRESS & TRAUMA TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LOCUST ST
ELDORADO IL
62930-1723
US

IV. Provider business mailing address

1200 LOCUST ST
ELDORADO IL
62930-1723
US

V. Phone/Fax

Practice location:
  • Phone: 270-997-1065
  • Fax: 618-216-9993
Mailing address:
  • Phone: 270-997-1065
  • Fax: 618-216-9993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. DONALD MATT BUCKMAN
Title or Position: EXECUTIVE DIRECTOR
Credential: PH D
Phone: 270-997-1065