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4505 W De Young St Ste 203 C Marion IL 62959-6295 | |
| (618) 292-1663 | |
| (618) 846-4381 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 4505 W De Young St, Marion, Illinois |
| Authorized Official Name and Position | Evonne Lanae Stephenson (DIRECTOR) |
| Authorized Official Contact | 6182921663 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4505 W Deyoung St Ste 203c Marion IL 62959-5899 Ph: (618) 292-1663 | 4505 W De Young St Ste 203 C Marion IL 62959-6295 Ph: (618) 292-1663 |
| NPI Number | 1043631351 |
|---|---|
| Provider Enumeration Date | 01/05/2014 |
| Last Update Date | 04/29/2022 |
| Certification Date | 09/16/2021 |
| Medicare PECOS PAC ID | 1355679010 |
|---|---|
| Medicare Enrollment ID | O20190820002466 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043631351 | NPI | - | NPPES |
| Provider Name | Jeffrey A. Brower |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1073623245 PECOS PAC ID: 8527087709 Enrollment ID: I20200204000369 |
| Provider Name | Evonne Lanae Stephenson |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1982914644 PECOS PAC ID: 2163750837 Enrollment ID: I20240320000495 |
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