Healthcare Provider Details

I. General information

NPI: 1124748546
Provider Name (Legal Business Name): YOUTH SERVICE BUREAU OF ILLINIOS VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4231 PROGRESS BLVD STE 1
PERU IL
61354-1193
US

IV. Provider business mailing address

424 W MADISON ST
OTTAWA IL
61350-2833
US

V. Phone/Fax

Practice location:
  • Phone: 815-433-3953
  • Fax: 815-433-3980
Mailing address:
  • Phone: 815-433-3953
  • Fax: 815-433-3980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE ROSALES
Title or Position: CLINICAL ADM ASST
Credential:
Phone: 815-433-3953