Healthcare Provider Details

I. General information

NPI: 1639594666
Provider Name (Legal Business Name): CYNTHIA M ROOT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 N 12TH ST
QUINCY IL
62301-1355
US

IV. Provider business mailing address

1707 N 12TH ST
QUINCY IL
62301-1355
US

V. Phone/Fax

Practice location:
  • Phone: 217-222-8641
  • Fax: 217-222-8578
Mailing address:
  • Phone: 217-222-8641
  • Fax: 217-222-8578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149009193
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: