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Organization
YOUTH SERVICE BUREAU OF ILLINOIS VALLEY
Active
Organization
YOUTH SERVICE BUREAU OF ILLINOIS VALLEY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. LISA KAY GUSTAFSON M.S. (TREATMENT COORDINATOR)
(815) 431-3022
Entity
Organization
Contact information
Practice address
424 W MADISON ST, OTTAWA, IL 61350-2833
(815) 433-3953
(815) 433-3980
Mailing address
424 W MADISON ST, OTTAWA, IL 61350-2833
(815) 433-3953
(815) 433-3980
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
1041C0700X
IL
251S00000X
Community/Behavioral Health Agency
149.013808
IL
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
149.013808
LICENSED CLINICAL SOCIAL WORKER
IL
Enumeration date
10/07/2009
Last updated
09/20/2022
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