| NPI | 1578808689 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LISA KAY GUSTAFSON Treatment Coordinator 815-433-3953 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 251S00000X (Licence: IL 1041C0700X) |
| Enumeration Date | 2012-11-29 |
| Last Update Date | 2022-09-20 |