=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326519356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAIM COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2018
-----------------------------------------------------
Last Update Date | 12/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4700 N PROSPECT RD STE A2C
-----------------------------------------------------
City | PEORIA HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61616-6473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-648-6549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4700 N PROSPECT RD STE A2C
-----------------------------------------------------
City | PEORIA HEIGHTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61616-6473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-648-6549
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY ELIZABETH CUNNINGHAM
-----------------------------------------------------
Credential | MA, LCPC
-----------------------------------------------------
Telephone | 309-648-6549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------