Healthcare Provider Details

I. General information

NPI: 1306710850
Provider Name (Legal Business Name): PROVISIONII BEHAVIORIAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 SW ADAMS ST
PEORIA IL
61602-1623
US

IV. Provider business mailing address

820 SW ADAMS ST
PEORIA IL
61602-1623
US

V. Phone/Fax

Practice location:
  • Phone: 309-223-4171
  • Fax: 309-223-4125
Mailing address:
  • Phone: 309-223-4171
  • Fax: 309-223-4125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRANDON M RUSSELL
Title or Position: FOUNDER & CEO
Credential:
Phone: 309-223-4171