Healthcare Provider Details

I. General information

NPI: 1114351947
Provider Name (Legal Business Name): CHESTNUT HEALTH SYSTEMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

IV. Provider business mailing address

448 WYLIE DR
NORMAL IL
61761-5405
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-6026
  • Fax: 309-820-3574
Mailing address:
  • Phone: 888-924-3786
  • Fax: 309-820-3574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number04023
License Number StateIL

VIII. Authorized Official

Name: MEGAN MARIE TAYLOR
Title or Position: MANAGED CARE SUPERVISOR
Credential:
Phone: 888-927-3786