Healthcare Provider Details

I. General information

NPI: 1396922084
Provider Name (Legal Business Name): YOUTH SERVICE BUREAU OF ROCK ISLAND CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 01/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4709 44TH ST SUITE 5
ROCK ISLAND IL
61201-7187
US

IV. Provider business mailing address

4709 44 STREET
ROCK ISLAND IL
61201
US

V. Phone/Fax

Practice location:
  • Phone: 309-793-3460
  • Fax: 309-732-0551
Mailing address:
  • Phone: 309-793-3460
  • Fax: 309-732-0551

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: MR. RICHARD J CONNOR
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 309-793-3460