=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265609465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AT HOME COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2008
-----------------------------------------------------
Last Update Date | 05/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 W WATER ST
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61764-1750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-842-1563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 W WATER ST
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61764-1750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-842-1563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER
-----------------------------------------------------
Name | DR. JUDY RIPSCH
-----------------------------------------------------
Credential | PH.D., L.C.S.W.
-----------------------------------------------------
Telephone | 815-842-1563
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149000420
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------