Healthcare Provider Details

I. General information

NPI: 1811730492
Provider Name (Legal Business Name): COUNTY OF HENRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N BURR BLVD
KEWANEE IL
61443-2214
US

IV. Provider business mailing address

110 N BURR BLVD
KEWANEE IL
61443-2214
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-5272
  • Fax:
Mailing address:
  • Phone: 309-852-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TARA LAFOLLETTE
Title or Position: CREDENTIALING REPRESENTATIVE
Credential:
Phone: 309-852-0197