Healthcare Provider Details

I. General information

NPI: 1063696912
Provider Name (Legal Business Name): DAVID LEWIS HEUSER M.S.ED., M.DIV.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 N MAIN ST SUITE 111
ROCKFORD IL
61103-1688
US

IV. Provider business mailing address

3703 N MAIN ST SUITE 111
ROCKFORD IL
61103-1688
US

V. Phone/Fax

Practice location:
  • Phone: 815-520-5361
  • Fax: 815-877-8172
Mailing address:
  • Phone: 815-520-5361
  • Fax: 815-877-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180006416
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: