Healthcare Provider Details

I. General information

NPI: 1184883779
Provider Name (Legal Business Name): FRESH START BEHAVIORIAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 SURREY BROOK PLZ
SAUK VILLAGE IL
60411-4913
US

IV. Provider business mailing address

8 SURREY BROOK PLZ
SAUK VILLAGE IL
60411-4913
US

V. Phone/Fax

Practice location:
  • Phone: 708-757-2444
  • Fax: 708-757-2449
Mailing address:
  • Phone: 708-757-2444
  • Fax: 708-757-2449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36093329
License Number StateIL

VIII. Authorized Official

Name: JOEL K CARROLL
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 708-757-2444