Healthcare Provider Details

I. General information

NPI: 1922752203
Provider Name (Legal Business Name): MS. EMILY MARIE ENBODEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. EMILY MARIE NIEBRUEGGE

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 W POINTE DR STE B
SWANSEA IL
62226-8302
US

IV. Provider business mailing address

208 W POINTE DR STE B
SWANSEA IL
62226-8302
US

V. Phone/Fax

Practice location:
  • Phone: 618-235-3857
  • Fax:
Mailing address:
  • Phone: 618-235-3857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178015441
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180014213
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: