Basic Information
| Provider Information | |||||||||
| NPI: | 1679078612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KINGSMILL | ||||||||
| FirstName: | CORTNEY | ||||||||
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| Credential: | LPC, QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 BROADWAY AVE E | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172385700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 AVENUE C | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174423200 | ||||||||
| FaxNumber: | 2174427460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2018 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 178.014729 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.