Provider Demographics
NPI:1124770235
Name:SERRANO, ISRAEL P (BS CADC MISA)
Entity type:Individual
Prefix:MR
First Name:ISRAEL
Middle Name:P
Last Name:SERRANO
Suffix:
Gender:M
Credentials:BS CADC MISA
Other - Prefix:MR
Other - First Name:ISRAEL
Other - Middle Name:P
Other - Last Name:SERRANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS CADC MISA
Mailing Address - Street 1:731 SABRINA DR UNIT C
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-3582
Mailing Address - Country:US
Mailing Address - Phone:309-699-9700
Mailing Address - Fax:309-699-2937
Practice Address - Street 1:731 SABRINA DR UNIT C
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-3582
Practice Address - Country:US
Practice Address - Phone:309-699-9700
Practice Address - Fax:309-699-2937
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12103101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)