Healthcare Provider Details

I. General information

NPI: 1619189594
Provider Name (Legal Business Name): COMMON BOUNDARY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1495 NORTHROCK CT
ROCKFORD IL
61103-1233
US

IV. Provider business mailing address

1495 NORTHROCK CT
ROCKFORD IL
61103-1233
US

V. Phone/Fax

Practice location:
  • Phone: 815-965-1817
  • Fax: 815-965-9574
Mailing address:
  • Phone: 815-965-1817
  • Fax: 815-965-9574

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: RENEE A MCARDLE
Title or Position: MANAGING PARTNER
Credential: PSY. D.
Phone: 815-965-1817