=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700654183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CLOCK INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2023
-----------------------------------------------------
Last Update Date | 12/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4102 46TH AVE
-----------------------------------------------------
City | ROCK ISLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61201-7166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-558-0956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4102 46TH AVE
-----------------------------------------------------
City | ROCK ISLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61201-7166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-558-0956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCPC
-----------------------------------------------------
Name | CHASE NORRIS
-----------------------------------------------------
Credential | LCPC, NCC
-----------------------------------------------------
Telephone | 309-558-0956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------