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General NPI Number Information
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NPI Number | 1710239793
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Entity Type | Organization
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Legal Business Name | MONARCH TRAUMA COUNSELING CENTER
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Dates
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Enumeration Date | 10/15/2012
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Last Update Date | 10/15/2012
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Provider Practice Location Address
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Address Line | 1630 5TH AVE SUITE 429
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City | MOLINE
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State | IL
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Zip | 61265-7914
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Country | US
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Telephone | 309-764-4733
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Fax | 309-764-2424
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Provider Business Mailing Address
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Address Line | 1630 5TH AVE SUITE 429
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City | MOLINE
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State | IL
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Zip | 61265
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Country | US
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Telephone | 309-764-4733
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Fax | 309-764-2424
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Authorized Official
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Title or Position | CO-OWNER
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Name | MRS. SALLY MELISSAS MISKINIS
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Credential | LCSW
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Telephone | 309-764-4733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180003695
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149014325
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License Number State | IL
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