Healthcare Provider Details

I. General information

NPI: 1396067559
Provider Name (Legal Business Name): ELLIOTT COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2010
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 OGLESBY AVE STE 300
NORMAL IL
61761-4616
US

IV. Provider business mailing address

1310 E GROVE ST
BLOOMINGTON IL
61701-4215
US

V. Phone/Fax

Practice location:
  • Phone: 309-212-3606
  • Fax: 312-789-4373
Mailing address:
  • Phone: 309-212-2496
  • Fax: 312-789-4373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number180004957
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: PAMELA JO ELLIOTT
Title or Position: MANAGER/OWNER
Credential:
Phone: 309-212-3606