Provider Demographics
NPI:1790040194
Name:CROSSROADS COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:CROSSROADS COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:V
Authorized Official - Last Name:BJORGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:815-578-4222
Mailing Address - Street 1:3510 CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60051-2506
Mailing Address - Country:US
Mailing Address - Phone:815-578-4222
Mailing Address - Fax:
Practice Address - Street 1:3510 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:JOHNSBURG
Practice Address - State:IL
Practice Address - Zip Code:60051-2506
Practice Address - Country:US
Practice Address - Phone:815-578-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006572101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty