Basic Information
| Provider Information | |||||||||
| NPI: | 1417926619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOVELAND | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172457275 | ||||||||
| FaxNumber: | 2172457427 | ||||||||
| Practice Location | |||||||||
| Address1: | 1515 W WALNUT ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626501159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172457275 | ||||||||
| FaxNumber: | 2172457427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149007051 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 8415589 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |