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General NPI Number Information
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NPI Number | 1619189594
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Entity Type | Organization
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Legal Business Name | COMMON BOUNDARY WELLNESS CENTER
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1495 NORTHROCK CT
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City | ROCKFORD
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State | IL
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Zip | 61103-1233
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Country | US
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Telephone | 815-965-1817
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Fax | 815-965-9574
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Provider Business Mailing Address
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Address Line | 1495 NORTHROCK CT
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City | ROCKFORD
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State | IL
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Zip | 61103-1233
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Country | US
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Telephone | 815-965-1817
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Fax | 815-965-9574
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | RENEE A MCARDLE
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Credential | PSY. D.
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Telephone | 815-965-1817
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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