Healthcare Provider Details

I. General information

NPI: 1730554064
Provider Name (Legal Business Name): CARLY KLOUBEC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 N UNIVERSITY DR
ROCKFORD IL
61107-5317
US

IV. Provider business mailing address

1021 N MULFORD RD
ROCKFORD IL
61107-3877
US

V. Phone/Fax

Practice location:
  • Phone: 805-391-1000
  • Fax: 815-391-5040
Mailing address:
  • Phone: 815-391-5600
  • Fax: 815-316-4726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178009262
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: