Healthcare Provider Details

I. General information

NPI: 1962014472
Provider Name (Legal Business Name): PREFERRED BEHAVIORAL HEALTH MSO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MARKET PL STE 100
FAIRVIEW HEIGHTS IL
62208-2089
US

IV. Provider business mailing address

141 MARKET PL STE 100
FAIRVIEW HEIGHTS IL
62208-2089
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-4226
  • Fax: 618-398-1759
Mailing address:
  • Phone: 618-398-4226
  • Fax: 618-398-1759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: RYAN W MORRIS
Title or Position: PRESIDENT
Credential:
Phone: 217-242-7718