Healthcare Provider Details

I. General information

NPI: 1235628975
Provider Name (Legal Business Name): AMANDA ROUSONELOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 WOODLAWN RD
STERLING IL
61081-4151
US

IV. Provider business mailing address

14047 IL HIGHWAY 40
BUDA IL
61314-9473
US

V. Phone/Fax

Practice location:
  • Phone: 815-625-0013
  • Fax:
Mailing address:
  • Phone: 815-878-1097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.011008
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180015789
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: