Healthcare Provider Details

I. General information

NPI: 1255571402
Provider Name (Legal Business Name): FAMILY CONNECTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2009
Last Update Date: 03/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 N SMILEY ST
O FALLON IL
62269-1231
US

IV. Provider business mailing address

PO BOX 122
O FALLON IL
62269-0122
US

V. Phone/Fax

Practice location:
  • Phone: 618-741-4123
  • Fax:
Mailing address:
  • Phone: 618-741-4123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number002882
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberWP32261106P
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1621340
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149006943
License Number StateIL

VIII. Authorized Official

Name: MRS. WENDY SUE BECKER PHILLIPS
Title or Position: MANAGING MEMBER
Credential: LCSW
Phone: 618-741-4123