Provider Demographics
NPI:1679010771
Name:QUAD CITIES MENTAL HEALTH
Entity Type:Organization
Organization Name:QUAD CITIES MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GONCHIGARI
Authorized Official - Middle Name:
Authorized Official - Last Name:NARAYANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-764-5040
Mailing Address - Street 1:4350 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6870
Mailing Address - Country:US
Mailing Address - Phone:309-764-5040
Mailing Address - Fax:309-764-9001
Practice Address - Street 1:4350 7TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6870
Practice Address - Country:US
Practice Address - Phone:309-764-5040
Practice Address - Fax:309-764-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.042316103TP0016X
IL180.006915251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty