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General NPI Number Information
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NPI Number | 1528387644
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Entity Type | Organization
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Legal Business Name | AEON SOCIAL EMOTIONAL HEALTH
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Dates
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Enumeration Date | 05/28/2010
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Last Update Date | 05/28/2010
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Provider Practice Location Address
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Address Line | 5016 N UNIVERSITY ST SUITE 109
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City | PEORIA
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State | IL
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Zip | 61614-4781
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Country | US
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Telephone | 309-573-4834
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Fax | 312-254-1423
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Provider Business Mailing Address
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Address Line | PO BOX 9665
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City | PEORIA
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State | IL
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Zip | 61612-9665
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KEVIN MCCLURE
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Credential | LCPC
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Telephone | 309-573-4834
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180006803
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License Number State | IL
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