=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669709648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLIANCES COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2009
-----------------------------------------------------
Last Update Date | 11/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 W 1ST ST SUITE 110
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021-3056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-285-3073
-----------------------------------------------------
Fax | 815-285-3103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 WEST FIRST STREET SUITE 110
-----------------------------------------------------
City | DIXON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61021-3056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-285-3073
-----------------------------------------------------
Fax | 815-285-3103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICIAN
-----------------------------------------------------
Name | BRIAN A SMITH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 815-285-3073
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 178006336
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------