Basic Information
| Provider Information | |||||||||
| NPI: | 1558327544 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JANET WATTLES CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANHATTAN COUNSELING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 526 W STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611011214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159689300 | ||||||||
| FaxNumber: | 8159685314 | ||||||||
| Practice Location | |||||||||
| Address1: | 526 W STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611011214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159689300 | ||||||||
| FaxNumber: | 8159685314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 06/14/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EATON | ||||||||
| AuthorizedOfficialFirstName: | PHIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8159689300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | BLUE CROSS | 01 | 10120962 | OTHER |