=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598992430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAFE HARBOR COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2009
-----------------------------------------------------
Last Update Date | 06/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 S MAIN ST STE A
-----------------------------------------------------
City | SUGAR GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60554-5023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-272-4959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 MARIE AVE
-----------------------------------------------------
City | YORKVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60560-1211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-272-4959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. BETH L PLACHETKA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 630-272-4959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149-008976
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------