Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 178.009748 | IL |
NPI | 1003234972 |
---|---|
Provider Name | Staci Poe |
First Address | Champaign, IL 61820-3636 |
Second Address | Champaign, IL 61820-3636 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2014 |
Last Update Date | 28/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
178.009748 | IDFPR (01) | IL |