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General NPI Number Information
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NPI Number | 1184863847
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Entity Type | Organization
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Legal Business Name | THE PRAIRIE CLINIC
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Dates
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Enumeration Date | 02/19/2009
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Last Update Date | 02/19/2009
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Provider Practice Location Address
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Address Line | 1541 E FABYAN PKWY SUITE 101
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City | GENEVA
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State | IL
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Zip | 60134-4105
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Country | US
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Telephone | 630-845-9644
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Fax | 630-845-9678
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Provider Business Mailing Address
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Address Line | 1541 E FABYAN PKWY SUITE 101
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City | GENEVA
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State | IL
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Zip | 60134-4105
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Country | US
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Telephone | 630-845-9644
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Fax | 630-845-9678
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. STACEY M WAHLBERG
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Credential |
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Telephone | 630-845-9644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 071006627
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License Number State | IL
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