Basic Information
| Provider Information | |||||||||
| NPI: | 1972699528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTMIX | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MHP, BS HUMAN SERVIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2704 RAY COURT | ||||||||
| Address2: | |||||||||
| City: | FOWLER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172230413 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4409 MAINE | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623053646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172230423 | ||||||||
| FaxNumber: | 2172230461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.