Healthcare Provider Details

I. General information

NPI: 1356726707
Provider Name (Legal Business Name): FAMILY COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E VINE ST SAME
VIENNA IL
62995-1612
US

IV. Provider business mailing address

408 E VINE ST
VIENNA IL
62995-1612
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-2611
  • Fax:
Mailing address:
  • Phone: 618-658-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIL

VIII. Authorized Official

Name: LAURA POTTS
Title or Position: BILLING LIAISON
Credential:
Phone: 618-658-2611