Provider Demographics
NPI:1922010537
Name:PRAIRIE PSYCHOTHERAPY ASSOCIATES, PC
Entity Type:Organization
Organization Name:PRAIRIE PSYCHOTHERAPY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LARK
Authorized Official - Middle Name:N
Authorized Official - Last Name:KIRCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-544-1632
Mailing Address - Street 1:1941 S SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3943
Mailing Address - Country:US
Mailing Address - Phone:217-544-1632
Mailing Address - Fax:217-544-4543
Practice Address - Street 1:1941 S SPRING ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3943
Practice Address - Country:US
Practice Address - Phone:217-544-1632
Practice Address - Fax:217-544-4543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210039Medicare ID - Type Unspecified