Provider Demographics
NPI:1922326875
Name:ROCK RIVER VALLEY MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:ROCK RIVER VALLEY MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:VAN DOREN
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:815-284-6111
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-0564
Mailing Address - Country:US
Mailing Address - Phone:815-284-6111
Mailing Address - Fax:815-284-6114
Practice Address - Street 1:631 WILLETT AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2348
Practice Address - Country:US
Practice Address - Phone:815-284-6111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-16
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007278261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health