Healthcare Provider Details

I. General information

NPI: 1689633828
Provider Name (Legal Business Name): WEBSTER-CANTRELL HALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1942 E CANTRELL ST
DECATUR IL
62521-3214
US

IV. Provider business mailing address

1942 E CANTRELL ST
DECATUR IL
62521-3214
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number021746-10
License Number StateIL

VIII. Authorized Official

Name: MR. MARTIN S HARRIS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 217-423-6961