Healthcare Provider Details

I. General information

NPI: 1073487088
Provider Name (Legal Business Name): REBECCA CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 S WATER TOWER PL
MOUNT VERNON IL
62864-6589
US

IV. Provider business mailing address

PO BOX 6
EWING IL
62836-0006
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-0212
  • Fax:
Mailing address:
  • Phone: 618-816-5247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.032857
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: