Provider Demographics
NPI:1952879546
Name:RIVERSIDE COUNSELING CENTER PLLC
Entity Type:Organization
Organization Name:RIVERSIDE COUNSELING CENTER PLLC
Other - Org Name:LINDSEY MCCLANATHAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EKBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-299-1955
Mailing Address - Street 1:6653 WEAVER RD STE 112
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6653 WEAVER RD STE 112
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8052
Practice Address - Country:US
Practice Address - Phone:815-201-2687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-13
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL311021632001Medicaid