Basic Information
Provider Information | |||||||||
NPI: | 1316455900 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOZARTH | ||||||||
FirstName: | RACHEL | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 155 | ||||||||
Address2: |   | ||||||||
City: | CHRISTOPHER | ||||||||
State: | IL | ||||||||
PostalCode: | 628220155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6187242401 | ||||||||
FaxNumber: | 6187244628 | ||||||||
Practice Location | |||||||||
Address1: | 119 GAS PLANT RD | ||||||||
Address2: |   | ||||||||
City: | DU QUOIN | ||||||||
State: | IL | ||||||||
PostalCode: | 628323866 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6187902146 | ||||||||
FaxNumber: | 6187902147 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2018 | ||||||||
LastUpdateDate: | 07/27/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 149.018753 | IL | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 149.018753 | IL | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.