Healthcare Provider Details

I. General information

NPI: 1124945209
Provider Name (Legal Business Name): REBEKAH THEILEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 S 6TH ST
SPRINGFIELD IL
62703-3454
US

IV. Provider business mailing address

4124 CAMP CILCA RD
CANTRALL IL
62625-8764
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-7150
  • Fax:
Mailing address:
  • Phone: 217-416-9596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178022746
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: