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General NPI Number Information
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NPI Number | 1033551320
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Entity Type | Organization
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Legal Business Name | STATELINE COUNSELING SERVICES LLC
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Dates
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Enumeration Date | 07/26/2013
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Last Update Date | 07/26/2013
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Provider Practice Location Address
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Address Line | 1107 N BLACKHAWK BLVD SUITE 8
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City | ROCKTON
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State | IL
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Zip | 61072-1500
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Country | US
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Telephone | 815-494-9115
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Fax | 815-926-5301
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Provider Business Mailing Address
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Address Line | 2218 CROSBY ST
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City | ROCKFORD
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State | IL
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Zip | 61107-4454
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Country | US
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Telephone | 815-464-9115
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Fax | 815-926-5301
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Authorized Official
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Title or Position | OWNER
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Name | MS. SHELLY LYNNE PATCHETT
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Credential | LCSW
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Telephone | 815-494-9115
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.009828
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License Number State | IL
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