Provider Demographics
NPI:1336179951
Name:HARRISBURG COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:HARRISBURG COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOSPODINOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-252-4956
Mailing Address - Street 1:100 DR WARREN TUTTLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946
Mailing Address - Country:US
Mailing Address - Phone:619-252-4956
Mailing Address - Fax:618-252-2032
Practice Address - Street 1:100 DR WARREN TUTTLE DRIVE
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946
Practice Address - Country:US
Practice Address - Phone:618-252-4956
Practice Address - Fax:618-252-2032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208762Medicare ID - Type UnspecifiedGROUP NUMBER
ILE36986Medicare UPIN