Provider Demographics
NPI:1396867420
Name:PRAIN, JOHN ROBERT (CADC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:PRAIN
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IL
Mailing Address - Zip Code:61415-0566
Mailing Address - Country:US
Mailing Address - Phone:309-465-3949
Mailing Address - Fax:
Practice Address - Street 1:900 S DEER RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-2639
Practice Address - Country:US
Practice Address - Phone:309-837-4876
Practice Address - Fax:309-833-1531
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22822101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL22822OtherCADC
IL370984175OtherFEIN BWAY, INC