Healthcare Provider Details

I. General information

NPI: 1578958062
Provider Name (Legal Business Name): DEBRA HAYES LCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E VINE ST
VIENNA IL
62995-1612
US

IV. Provider business mailing address

1414 W MAIN ST
MARION IL
62959-1142
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-2611
  • Fax:
Mailing address:
  • Phone: 618-364-5128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.010730
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: