Healthcare Provider Details

I. General information

NPI: 1396415121
Provider Name (Legal Business Name): AMANDA REZIN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA GREEN

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 08/31/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 N PERRYVILLE RD STE 4
ROCKFORD IL
61107-6225
US

IV. Provider business mailing address

695 N PERRYVILLE RD STE 4
ROCKFORD IL
61107-6225
US

V. Phone/Fax

Practice location:
  • Phone: 779-368-0060
  • Fax: 815-977-4892
Mailing address:
  • Phone: 779-368-0060
  • Fax: 815-977-4892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178-016094
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180014340
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: