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108 W Market St Bloomington IL 61701-3918 | |
| (309) 827-5351 | |
| (309) 829-6808 |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 108 W Market St, Bloomington, Illinois |
| Authorized Official Name and Position | Thomas Barr (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 3098275351 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
108 W Market St Bloomington IL 61701-3918 Ph: (309) 827-5351 | 108 W Market St Bloomington IL 61701-3918 Ph: (309) 827-5351 |
| NPI Number | 1245233493 |
|---|---|
| Provider Enumeration Date | 05/23/2005 |
| Last Update Date | 01/26/2022 |
| Certification Date | 01/26/2022 |
| Medicare PECOS PAC ID | 5991752784 |
|---|---|
| Medicare Enrollment ID | O20050404000973 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1245233493 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Secondary |
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Elizabeth J Robert |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1013275007 PECOS PAC ID: 8325204118 Enrollment ID: I20120723000944 |
| Provider Name | Julie A Gifford |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1750716734 PECOS PAC ID: 8123253812 Enrollment ID: I20131105001750 |
| Provider Name | Diane M Walker |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1427467422 PECOS PAC ID: 7618197815 Enrollment ID: I20141010001647 |
| Provider Name | Lori J Farley |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1558463604 PECOS PAC ID: 9032432604 Enrollment ID: I20150107000276 |
| Provider Name | Theresa Lynn Kauth |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1003211012 PECOS PAC ID: 3476877853 Enrollment ID: I20150112002107 |
| Provider Name | Darci Newton |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1457780082 PECOS PAC ID: 7517235914 Enrollment ID: I20170607001285 |
| Provider Name | Crystal Cargill |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1407335854 PECOS PAC ID: 2163773128 Enrollment ID: I20181002000235 |
| Provider Name | Bettina S Ervin-rodgers |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1922583285 PECOS PAC ID: 9436403995 Enrollment ID: I20181120000124 |
| Provider Name | Myranda A Whitman |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1841600608 PECOS PAC ID: 3779977376 Enrollment ID: I20220224001976 |
| Provider Name | Jodi L Huffman-frazee |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1649962580 PECOS PAC ID: 7719334697 Enrollment ID: I20231115000151 |
| Provider Name | Natasha Nunoo-ponder |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1295086114 PECOS PAC ID: 2365887676 Enrollment ID: I20240227000626 |
| Provider Name | Meghan E Moser |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1588843668 PECOS PAC ID: 7719322023 Enrollment ID: I20240227000645 |
| Provider Name | Melody J Ellis |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1760145528 PECOS PAC ID: 2961847280 Enrollment ID: I20240227001155 |
| Provider Name | Mary C Crites |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1083160444 PECOS PAC ID: 6103261268 Enrollment ID: I20240228002142 |
| Provider Name | James S Decremer |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1821377581 PECOS PAC ID: 2961849948 Enrollment ID: I20240326003246 |
| Provider Name | Camille B Cales |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1821429176 PECOS PAC ID: 1153769286 Enrollment ID: I20240409000710 |
| Provider Name | Robert J Wolter |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1053796367 PECOS PAC ID: 4981042363 Enrollment ID: I20240719003156 |
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