Healthcare Provider Details

I. General information

NPI: 1457993032
Provider Name (Legal Business Name): SARAH REYNERTSON COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 E MAIN ST
URBANA IL
61802-2830
US

IV. Provider business mailing address

1210 E MAIN ST
URBANA IL
61802-2830
US

V. Phone/Fax

Practice location:
  • Phone: 217-615-2782
  • Fax: 217-484-8932
Mailing address:
  • Phone: 217-615-2782
  • Fax: 217-484-8932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SARAH REYNERTSON
Title or Position: OWNER
Credential: LCPC
Phone: 217-615-2782