Healthcare Provider Details

I. General information

NPI: 1225397136
Provider Name (Legal Business Name): WILLIAM LEE BISHOP L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 04/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 TAYLOR LAKE DR
TROY IL
62294-1298
US

IV. Provider business mailing address

132 TAYLOR LAKE DR
TROY IL
62294-1298
US

V. Phone/Fax

Practice location:
  • Phone: 618-314-0172
  • Fax:
Mailing address:
  • Phone: 618-314-0172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149.011023
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: