Provider Demographics
NPI:1750635686
Name:RALSTON, DEBORAH S
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:S
Last Name:RALSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-0516
Mailing Address - Country:US
Mailing Address - Phone:618-943-3754
Mailing Address - Fax:618-943-3657
Practice Address - Street 1:11020 STATE ROUTE 250
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-3379
Practice Address - Country:US
Practice Address - Phone:618-943-3754
Practice Address - Fax:618-943-3657
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376006178008Medicaid
IL207184Medicare PIN
IL376006178008Medicaid