Healthcare Provider Details

I. General information

NPI: 1588313225
Provider Name (Legal Business Name): PRAIRIELAND COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6035 N KNOXVILLE AVE STE 204B
PEORIA IL
61614-3504
US

IV. Provider business mailing address

6035 N KNOXVILLE AVE STE 204B
PEORIA IL
61614-3504
US

V. Phone/Fax

Practice location:
  • Phone: 309-704-4664
  • Fax:
Mailing address:
  • Phone: 309-704-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HANNAH SPENCER
Title or Position: OWNER
Credential: LCPC
Phone: 309-704-4664