| NPI | 1134612054 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LATOSHA R DAVIS Executive Director 618-219-9513 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0855X Clinic/Center Adolescent and Children Mental Health (Licence: IL 149.019998) |
| Additional Taxonomies | 261QM0801X Clinic/Center Mental Health (Including Community Mental Health Center) (Licence: IL 149.019998) |
| 261QM0850X Clinic/Center Adult Mental Health (Licence: IL 149.019998) | |
| Enumeration Date | 2018-06-14 |
| Last Update Date | 2018-06-14 |