Healthcare Provider Details

I. General information

NPI: 1194336784
Provider Name (Legal Business Name): EARTH WATER AIR COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2020
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 FORTUNE BLVD STE 200
SHILOH IL
62269-7385
US

IV. Provider business mailing address

1161 FORTUNE BLVD STE 200
SHILOH IL
62269-7385
US

V. Phone/Fax

Practice location:
  • Phone: 618-777-6670
  • Fax: 877-811-5628
Mailing address:
  • Phone: 618-777-6670
  • Fax: 877-811-5628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SCARLETT MARIA MEYER
Title or Position: OWNER/COUNSELOR
Credential: LCPC
Phone: 217-242-7451