=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982439931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE PEDIATRIC CLINIC FOR BEHAVIORAL HEALTH, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2024
-----------------------------------------------------
Last Update Date | 01/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2012 VANDALIA ST
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62234-4848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-999-6373
-----------------------------------------------------
Fax | 618-350-0083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2012 VANDALIA ST
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62234-4848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-999-6373
-----------------------------------------------------
Fax | 618-350-0083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BETHANY RADCLIFFE
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 331-442-4249
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------