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General NPI Number Information
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NPI Number | 1710610613
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Entity Type | Organization
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Legal Business Name | PERSIMMON TREE COUNSELING, LLC
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Dates
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Enumeration Date | 07/07/2022
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Last Update Date | 07/12/2022
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Provider Practice Location Address
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Address Line | 207 W JEFFERSON ST STE 401
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City | BLOOMINGTON
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State | IL
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Zip | 61701-3969
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Country | US
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Telephone | 309-431-1296
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Fax |
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Provider Business Mailing Address
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Address Line | 807 S GROVE ST
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City | NORMAL
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State | IL
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Zip | 61761-2840
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Country | US
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Telephone | 309-287-6379
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MATTHEW HICKMAN
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Credential | LCPC
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Telephone | 309-431-1296
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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