Provider Demographics
NPI:1538526488
Name:CENTER FOR MARRIAGE AND FAMILY, INC.
Entity type:Organization
Organization Name:CENTER FOR MARRIAGE AND FAMILY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SELANDER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-520-6972
Mailing Address - Street 1:4615 E STATE ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2100
Mailing Address - Country:US
Mailing Address - Phone:815-391-3055
Mailing Address - Fax:
Practice Address - Street 1:4615 E STATE ST
Practice Address - Street 2:SUITE 130
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2100
Practice Address - Country:US
Practice Address - Phone:815-391-3055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-23
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490176031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty