=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508235540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVOCACY COUNSELING CENTER, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2015
-----------------------------------------------------
Last Update Date | 09/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 44 N VIRGINIA ST SUITE 2B
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60014-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-243-6789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 N VIRGINIA ST SUITE 2B
-----------------------------------------------------
City | CRYSTAL LAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60014-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-243-6789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLA WERTHEIMER
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 815-243-6789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071005699
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------