Provider Demographics
NPI:1184938730
Name:EPHPHATHA CONSULTING SERVICES, INC.
Entity type:Organization
Organization Name:EPHPHATHA CONSULTING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENTON
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:II
Authorized Official - Credentials:PHD
Authorized Official - Phone:309-558-9050
Mailing Address - Street 1:2424 40TH AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7215
Mailing Address - Country:US
Mailing Address - Phone:309-558-9050
Mailing Address - Fax:
Practice Address - Street 1:2424 40TH AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7215
Practice Address - Country:US
Practice Address - Phone:309-558-9050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2013-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001063101YM0800X
IL180006524101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty