Provider Demographics
NPI:1376544387
Name:CENTENNIAL COUNSELING CENTER, PC
Entity Type:Organization
Organization Name:CENTENNIAL COUNSELING CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUHRT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:630-377-6613
Mailing Address - Street 1:1120 E MAIN ST
Mailing Address - Street 2:STE. 201
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2287
Mailing Address - Country:US
Mailing Address - Phone:630-377-6613
Mailing Address - Fax:630-377-6225
Practice Address - Street 1:1120 E MAIN ST
Practice Address - Street 2:STE. 201
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2287
Practice Address - Country:US
Practice Address - Phone:630-377-6613
Practice Address - Fax:630-377-6225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-007517101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214626Medicare UPIN