Provider Demographics
NPI:1376200550
Name:BEACON OF ENLIGHTENMENT
Entity Type:Organization
Organization Name:BEACON OF ENLIGHTENMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRISY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:815-564-8633
Mailing Address - Street 1:6072 BRYNWOOD DR STE 201
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5829
Mailing Address - Country:US
Mailing Address - Phone:815-564-8633
Mailing Address - Fax:779-423-0778
Practice Address - Street 1:6072 BRYNWOOD DR STE 201
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5829
Practice Address - Country:US
Practice Address - Phone:815-564-8633
Practice Address - Fax:779-423-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-22
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty