Healthcare Provider Details

I. General information

NPI: 1679198246
Provider Name (Legal Business Name): RENEE ZOLL QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 N WATER TOWER PL
MOUNT VERNON IL
62864-6295
US

IV. Provider business mailing address

605 GREEN ST
WOODLAWN IL
62898-1105
US

V. Phone/Fax

Practice location:
  • Phone: 618-534-4250
  • Fax: 618-242-1150
Mailing address:
  • Phone: 618-534-4250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: