Healthcare Provider Details

I. General information

NPI: 1053613307
Provider Name (Legal Business Name): EVERETT OLIVER IRBY CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3248 VANDEVER AVENUE
PEKIN IL
61554
US

IV. Provider business mailing address

3248 VANDEVER AVENUE
PEKIN IL
61554
US

V. Phone/Fax

Practice location:
  • Phone: 309-347-5579
  • Fax: 309-347-4264
Mailing address:
  • Phone: 309-347-5579
  • Fax: 309-347-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: