Healthcare Provider Details

I. General information

NPI: 1710239793
Provider Name (Legal Business Name): MONARCH TRAUMA COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 5TH AVE SUITE 429
MOLINE IL
61265-7914
US

IV. Provider business mailing address

1630 5TH AVE SUITE 429
MOLINE IL
61265
US

V. Phone/Fax

Practice location:
  • Phone: 309-764-4733
  • Fax: 309-764-2424
Mailing address:
  • Phone: 309-764-4733
  • Fax: 309-764-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003695
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014325
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. SALLY MELISSAS MISKINIS
Title or Position: CO-OWNER
Credential: LCSW
Phone: 309-764-4733