Healthcare Provider Details

I. General information

NPI: 1922945542
Provider Name (Legal Business Name): CENTRAL ILLINOIS FRIENDS OF PWA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 E WAR MEMORIAL DR
PEORIA IL
61614-8002
US

IV. Provider business mailing address

2112 E WAR MEMORIAL DR
PEORIA IL
61614-8002
US

V. Phone/Fax

Practice location:
  • Phone: 309-431-5880
  • Fax:
Mailing address:
  • Phone: 309-431-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DERIC KIMLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 309-431-5880