Provider Demographics
NPI:1033551320
Name:STATELINE COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:STATELINE COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:PATCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-494-9115
Mailing Address - Street 1:2218 CROSBY ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-4454
Mailing Address - Country:US
Mailing Address - Phone:815-464-9115
Mailing Address - Fax:815-926-5301
Practice Address - Street 1:1107 N BLACKHAWK BLVD
Practice Address - Street 2:SUITE 8
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-1500
Practice Address - Country:US
Practice Address - Phone:815-494-9115
Practice Address - Fax:815-926-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0098281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty