Healthcare Provider Details

I. General information

NPI: 1548587603
Provider Name (Legal Business Name): CATHOLIC CHARITIES OF THE DIOCESE OF PEORIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W HEADING AVE
WEST PEORIA IL
61604-4868
US

IV. Provider business mailing address

2900 W HEADING AVE
WEST PEORIA IL
61604-4868
US

V. Phone/Fax

Practice location:
  • Phone: 309-636-8012
  • Fax: 309-636-8097
Mailing address:
  • Phone: 309-636-8012
  • Fax: 309-636-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PATRICIA C FOX
Title or Position: INTERIM EXECUTIVE DIRECTOR
Credential: MA
Phone: 309-636-8012