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General NPI Number Information
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NPI Number | 1326456914
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Entity Type | Organization
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Legal Business Name | ALCOHOL & DRUG EDUCATION CLINIC, INC.
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Dates
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Enumeration Date | 07/27/2014
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Last Update Date | 07/27/2014
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Provider Practice Location Address
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Address Line | 2052 3RD AVE
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City | ROCK ISLAND
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State | IL
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Zip | 61201-8803
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Country | US
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Telephone | 309-794-1097
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Fax |
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Provider Business Mailing Address
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Address Line | 2052 3RD AVE
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City | ROCK ISLAND
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State | IL
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Zip | 61201-8803
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Country | US
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Telephone | 309-794-1097
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JOHN MICHAEL WALSH
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Credential | LCPC, CADC
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Telephone | 309-794-1097
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | A330800003A
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License Number State | IL
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