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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