Basic Information
| Provider Information | |||||||||
| NPI: | 1497002679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUELLER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | JERALD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 232 MCMILLAN CT | ||||||||
| Address2: | APT. 201 | ||||||||
| City: | CORTLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601124169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152992560 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8616 NORTHERN AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611075309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159793402 | ||||||||
| FaxNumber: | 8153326090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2012 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 178.007967 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1497002679 | 01 | IL | NATIONAL PROVIDER IDENTIFIER | OTHER |