Healthcare Provider Details

I. General information

NPI: 1598844151
Provider Name (Legal Business Name): SANDRA K EADES LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 PIPER GLEN DR SUITE C
SPRINGFIELD IL
62711
US

IV. Provider business mailing address

7000 PIPER GLEN DR SUITE C
SPRINGFIELD IL
62711
US

V. Phone/Fax

Practice location:
  • Phone: 217-483-7104
  • Fax: 817-483-7109
Mailing address:
  • Phone: 217-483-7104
  • Fax: 817-483-7109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: