Basic Information
| Provider Information | |||||||||
| NPI: | 1750614798 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH CENTERS OF CENTRAL ILLINOIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL BEHAVIORAL HEALTH COUNSELING ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3428 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627083428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005775368 | ||||||||
| FaxNumber: | 2177572021 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 N 1ST ST | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627023759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177884065 | ||||||||
| FaxNumber: | 2177884147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOWLING | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2175882626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.