Provider Demographics
NPI:1295897148
Name:ROCKLAND PROFESSIONAL GROUP LLC
Entity type:Organization
Organization Name:ROCKLAND PROFESSIONAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:A
Authorized Official - Last Name:SISLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-816-9180
Mailing Address - Street 1:114 W ROCKLAND RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2774
Mailing Address - Country:US
Mailing Address - Phone:847-816-9180
Mailing Address - Fax:847-816-9183
Practice Address - Street 1:114 W ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2774
Practice Address - Country:US
Practice Address - Phone:847-816-9180
Practice Address - Fax:847-816-9183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04920480OtherBLUE CROSS BLUE SHIELD