Healthcare Provider Details

I. General information

NPI: 1922010537
Provider Name (Legal Business Name): PRAIRIE PSYCHOTHERAPY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 S SPRING ST
SPRINGFIELD IL
62704-3943
US

IV. Provider business mailing address

1941 S SPRING ST
SPRINGFIELD IL
62704-3943
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-1632
  • Fax: 217-544-4543
Mailing address:
  • Phone: 217-544-1632
  • Fax: 217-544-4543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name: MS. LARK N KIRCHNER
Title or Position: PRESIDENT
Credential: LCSW
Phone: 217-544-1632