Provider Demographics
NPI:1851554224
Name:MINDOCK COUNSELING AND CONSULTING
Entity Type:Organization
Organization Name:MINDOCK COUNSELING AND CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:FUNDELL
Authorized Official - Last Name:MINDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-696-4697
Mailing Address - Street 1:3100 N DRIES LN
Mailing Address - Street 2:SUITE 302
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1259
Mailing Address - Country:US
Mailing Address - Phone:309-696-4697
Mailing Address - Fax:309-681-0381
Practice Address - Street 1:3100 N DRIES LN
Practice Address - Street 2:SUITE 302
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1259
Practice Address - Country:US
Practice Address - Phone:309-696-4697
Practice Address - Fax:309-681-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty