Healthcare Provider Details

I. General information

NPI: 1720368608
Provider Name (Legal Business Name): FAMILY COUNSELING CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N MARKET ST
GOLCONDA IL
62938-1136
US

IV. Provider business mailing address

125 N MARKET ST
GOLCONDA IL
62938-1136
US

V. Phone/Fax

Practice location:
  • Phone: 618-683-2461
  • Fax:
Mailing address:
  • Phone: 618-683-2461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number04055
License Number StateIL

VIII. Authorized Official

Name: TERESA PICKERING
Title or Position: COMPUTER BILLING
Credential:
Phone: 618-658-2611