Provider Demographics
NPI:1679846075
Name:JOHN, ROSEMARY IRENE (CRSS, CADC)
Entity type:Individual
Prefix:MS
First Name:ROSEMARY
Middle Name:IRENE
Last Name:JOHN
Suffix:
Gender:F
Credentials:CRSS, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3352
Mailing Address - Country:US
Mailing Address - Phone:309-836-1582
Mailing Address - Fax:309-836-1576
Practice Address - Street 1:505 E GRANT ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3352
Practice Address - Country:US
Practice Address - Phone:309-836-1582
Practice Address - Fax:309-836-1576
Is Sole Proprietor?:No
Enumeration Date:2012-02-15
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL30141101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)