Provider Demographics
NPI:1598162554
Name:ROCKFORD ANXIETY AND PHOBIC CLINIC
Entity Type:Organization
Organization Name:ROCKFORD ANXIETY AND PHOBIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:DOY
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MED
Authorized Official - Phone:815-762-0903
Mailing Address - Street 1:429 PHELPS AVE
Mailing Address - Street 2:BUILDING 7 SUITE 11
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2493
Mailing Address - Country:US
Mailing Address - Phone:815-762-0903
Mailing Address - Fax:779-500-0687
Practice Address - Street 1:429 PHELPS AVE
Practice Address - Street 2:BUILDING 7 SUITE 11
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2493
Practice Address - Country:US
Practice Address - Phone:815-762-0903
Practice Address - Fax:779-500-0687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000119251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health