Provider Demographics
NPI:1245661057
Name:PRAIRIE WELLNESS COUNSELING CENTER, P.C.
Entity type:Organization
Organization Name:PRAIRIE WELLNESS COUNSELING CENTER, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLES
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LCPC
Authorized Official - Phone:630-715-5740
Mailing Address - Street 1:12 W WILSON ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-2891
Mailing Address - Country:US
Mailing Address - Phone:630-715-5740
Mailing Address - Fax:
Practice Address - Street 1:12 W WILSON ST
Practice Address - Street 2:SUITE A
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-2891
Practice Address - Country:US
Practice Address - Phone:630-715-5740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty