Healthcare Provider Details

I. General information

NPI: 1396867420
Provider Name (Legal Business Name): JOHN ROBERT PRAIN CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S DEER RD
MACOMB IL
61455-2639
US

IV. Provider business mailing address

PO BOX 566
AVON IL
61415-0566
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-4876
  • Fax: 309-833-1531
Mailing address:
  • Phone: 309-465-3949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number22822
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22822
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: