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General NPI Number Information
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NPI Number | 1598162554
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Entity Type | Organization
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Legal Business Name | ROCKFORD ANXIETY AND PHOBIC CLINIC
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Dates
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Enumeration Date | 11/19/2014
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Last Update Date | 11/19/2014
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Provider Practice Location Address
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Address Line | 429 PHELPS AVE BUILDING 7 SUITE 11
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City | ROCKFORD
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State | IL
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Zip | 61108-2493
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Country | US
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Telephone | 815-762-0903
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Fax | 779-500-0687
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Provider Business Mailing Address
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Address Line | 429 PHELPS AVE BUILDING 7 SUITE 11
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City | ROCKFORD
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State | IL
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Zip | 61108-2493
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Country | US
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Telephone | 815-762-0903
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Fax | 779-500-0687
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Authorized Official
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Title or Position | OWNER
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Name | MR. CHARLES DOY DUDLEY JR.
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Credential | M.ED
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Telephone | 815-762-0903
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 180000119
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License Number State | IL
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