Basic Information
Provider Information | |||||||||
NPI: | 1083004832 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MEINERT | ||||||||
FirstName: | JOANNA | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MHP, CRADC, MISA I | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 580 8TH ST | ||||||||
Address2: |   | ||||||||
City: | CARLYLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622311803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185944581 | ||||||||
FaxNumber: | 6185948482 | ||||||||
Practice Location | |||||||||
Address1: | 580 8TH ST | ||||||||
Address2: |   | ||||||||
City: | CARLYLE | ||||||||
State: | IL | ||||||||
PostalCode: | 622311803 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185944581 | ||||||||
FaxNumber: | 6185948482 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2015 | ||||||||
LastUpdateDate: | 02/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 17695 | IL | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 017695 | 01 | IL | DASA- DEPT OF ALCOHOL AND SUBSTANCE ABUSE | OTHER |