=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427205111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS COUNSELING SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2008
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1802 N DIVISION ST STE 509
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-941-3882
-----------------------------------------------------
Fax | 815-941-3884
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1802 N DIVISION ST STE 509
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-941-3882
-----------------------------------------------------
Fax | 815-941-3884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANGELA C SOLIS
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 815-941-3882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 14623
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180003593
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149011760
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------