Healthcare Provider Details

I. General information

NPI: 1710518741
Provider Name (Legal Business Name): WEBSTER CANTRELL YOUTH ADVOCACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E ELDORADO ST
DECATUR IL
62523-1039
US

IV. Provider business mailing address

1942 E CANTRELL ST
DECATUR IL
62521-3214
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-7864
  • Fax: 217-422-1324
Mailing address:
  • Phone: 217-423-6961
  • Fax: 217-421-6889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL WARNER
Title or Position: CEO
Credential: MS,ED, LCPC, CADC
Phone: 217-423-6961