Healthcare Provider Details

I. General information

NPI: 1629510367
Provider Name (Legal Business Name): VERONICA DURDELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 N ILLINOIS ROUTE 3
WATERLOO IL
62298-1000
US

IV. Provider business mailing address

988 N ILLINOIS ROUTE 3 PO BOX 146
WATERLOO IL
62298-1000
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4444
  • Fax: 618-939-4181
Mailing address:
  • Phone: 618-939-4444
  • Fax: 618-939-4181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: