Healthcare Provider Details

I. General information

NPI: 1265376446
Provider Name (Legal Business Name): ENERI BEHAVIORAL HEALTH SECOND GENERATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2026
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD STE N
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

21141 GOVERNORS HWY STE 114
MATTESON IL
60443-3818
US

V. Phone/Fax

Practice location:
  • Phone: 773-234-2788
  • Fax: 805-244-0428
Mailing address:
  • Phone: 773-234-2788
  • Fax: 805-244-0428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JULIA JOHNSON
Title or Position: CLINICIAN
Credential: APRN
Phone: 773-234-2788