Healthcare Provider Details

I. General information

NPI: 1306804281
Provider Name (Legal Business Name): CRISTINA LYNN MUGRAGE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRISTINA LYNN ZELLERS MSW

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 12/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N PROSPECT RD SUITE A1
PEORIA HEIGHTS IL
61616-6451
US

IV. Provider business mailing address

220 ORLANDO AVE
NORMAL IL
61761-1356
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.011980
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: