Healthcare Provider Details

I. General information

NPI: 1053764175
Provider Name (Legal Business Name): JOAN WHALEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 FAIRVIEW DR
ROCHELLE IL
61068-2310
US

IV. Provider business mailing address

707 1ST AVE
ROCHELLE IL
61068-1815
US

V. Phone/Fax

Practice location:
  • Phone: 815-561-9003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: