Healthcare Provider Details

I. General information

NPI: 1063638583
Provider Name (Legal Business Name): DARYLNN JEAN PEART MS LPHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 E COLLEGE ST
KEWANEE IL
61443-3703
US

IV. Provider business mailing address

24883 CO HWY 14 1370 N
ANNAWAN IL
61234
US

V. Phone/Fax

Practice location:
  • Phone: 309-854-0122
  • Fax:
Mailing address:
  • Phone: 309-935-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number370984175
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: