Provider Demographics
NPI:1558327544
Name:JANET WATTLES CENTER
Entity Type:Organization
Organization Name:JANET WATTLES CENTER
Other - Org Name:MANHATTAN COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-968-9300
Mailing Address - Street 1:526 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1214
Mailing Address - Country:US
Mailing Address - Phone:815-968-9300
Mailing Address - Fax:815-968-5314
Practice Address - Street 1:526 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-1214
Practice Address - Country:US
Practice Address - Phone:815-968-9300
Practice Address - Fax:815-968-5314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
BLUE CROSSOther10120962
IL=========001Medicaid
IL=========001Medicaid