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General NPI Number Information
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NPI Number | 1669858536
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Entity Type | Organization
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Legal Business Name | PEACE OF MIND COUNSELING, LLC
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Dates
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Enumeration Date | 08/03/2015
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Last Update Date | 03/08/2016
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Provider Practice Location Address
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Address Line | 2016 VADALABENE DR STE A
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City | MARYVILLE
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State | IL
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Zip | 62062-6901
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Country | US
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Telephone | 618-823-6444
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Fax | 618-551-8456
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Provider Business Mailing Address
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Address Line | 2016 VADALABENE DR STE A
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City | MARYVILLE
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State | IL
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Zip | 62062-6901
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Country | US
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Telephone | 618-823-6444
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Fax | 618-551-8456
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Authorized Official
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Title or Position | OWNER
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Name | DIANE BRACAMONTES
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Credential | LCSW
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Telephone | 618-823-6444
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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 | 149.013539
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License Number State | IL
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