Healthcare Provider Details

I. General information

NPI: 1073067138
Provider Name (Legal Business Name): GALENA CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2016
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 GALENA SQUARE DR
GALENA IL
61036
US

IV. Provider business mailing address

939 GALENA SQUARE DR
GALENA IL
61036-1355
US

V. Phone/Fax

Practice location:
  • Phone: 815-777-1300
  • Fax: 815-777-1308
Mailing address:
  • Phone: 815-777-1300
  • Fax: 815-777-1308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number14011
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number14011
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number14011
License Number StateIL

VIII. Authorized Official

Name: DR. KENNETH DAVIS
Title or Position: PRESIDENT
Credential: M.D., PH.D.
Phone: 815-777-1300