Healthcare Provider Details

I. General information

NPI: 1770718439
Provider Name (Legal Business Name): COMMUNITY RESOURCE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 01/03/2020
Certification Date: 01/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 WESTGATE
SALEM IL
62881
US

IV. Provider business mailing address

904 E MARTIN LUTHER KING DRIVE
CENTRALIA IL
62801-3058
US

V. Phone/Fax

Practice location:
  • Phone: 618-548-2181
  • Fax: 618-548-1035
Mailing address:
  • Phone: 618-533-1391
  • Fax: 618-533-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: GEORGIANNE BROUGHTON
Title or Position: EXECUTIVE DIRECTOR
Credential: LPHA, LCPC
Phone: 618-533-1391