Healthcare Provider Details

I. General information

NPI: 1952879546
Provider Name (Legal Business Name): RIVERSIDE COUNSELING CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6653 WEAVER RD STE 112
ROCKFORD IL
61114-8052
US

IV. Provider business mailing address

6653 WEAVER RD STE 112
ROCKFORD IL
61114-8052
US

V. Phone/Fax

Practice location:
  • Phone: 815-201-2687
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KIRSTEN EKBERG
Title or Position: CONTRACTING
Credential:
Phone: 815-299-1955