Provider Demographics
NPI:1710239793
Name:MONARCH TRAUMA COUNSELING CENTER
Entity Type:Organization
Organization Name:MONARCH TRAUMA COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:MELISSAS
Authorized Official - Last Name:MISKINIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:309-764-4733
Mailing Address - Street 1:1630 5TH AVE
Mailing Address - Street 2:SUITE 429
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265
Mailing Address - Country:US
Mailing Address - Phone:309-764-4733
Mailing Address - Fax:309-764-2424
Practice Address - Street 1:1630 5TH AVE
Practice Address - Street 2:SUITE 429
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7914
Practice Address - Country:US
Practice Address - Phone:309-764-4733
Practice Address - Fax:309-764-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180003695101YP2500X
IL1490143251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty