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General NPI Number Information
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NPI Number | 1306710850
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Entity Type | Organization
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Legal Business Name | PROVISIONII BEHAVIORIAL HEALTH LLC
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Dates
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Enumeration Date | 09/29/2025
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Last Update Date | 09/29/2025
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Provider Practice Location Address
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Address Line | 820 SW ADAMS ST
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City | PEORIA
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State | IL
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Zip | 61602-1623
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Country | US
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Telephone | 309-223-4171
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Fax | 309-223-4125
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Provider Business Mailing Address
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Address Line | 820 SW ADAMS ST
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City | PEORIA
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State | IL
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Zip | 61602-1623
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Country | US
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Telephone | 309-223-4171
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Fax | 309-223-4125
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Authorized Official
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Title or Position | FOUNDER & CEO
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Name | BRANDON M RUSSELL
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Credential |
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Telephone | 309-223-4171
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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