Healthcare Provider Details

I. General information

NPI: 1437468105
Provider Name (Legal Business Name): JULIE M STOLL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2010
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E LINCOLN ST SUITE 302
NORMAL IL
61761-6406
US

IV. Provider business mailing address

1706 SUNRISE PT
NORMAL IL
61761-5629
US

V. Phone/Fax

Practice location:
  • Phone: 309-212-3606
  • Fax: 888-474-1956
Mailing address:
  • Phone: 309-533-2432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149013668
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: