MEDICARE: FAMILY SERVICE AND COMMUNITY MENTAL HEALTH CENTER FOR MCHENRY COUNTY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5615096	OTHER	IL	BLUE CROSS
2	5615096	OTHER	IL	BLUE SHIELD

General Provider Information

NPI Number	:	1396795522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY SERVICE AND COMMUNITY MENTAL HEALTH CENTER FOR MCHENRY COUNTY

Provider Business Mailing Address
First Line	:	4100 VETERANS PKWY
Second Line	:
City	:	MCHENRY
State	:	IL
Zip	:	60050-4029
Country	:	US
Telephone Number	:	815-385-6400
Fax Number	:	815-385-8127

Provider Business Practice Location Address
First Line	:	4100 VETERANS PKWY
Second Line	:
City	:	MCHENRY
State	:	IL
Zip	:	60050-4029
Country	:	US
Telephone Number	:	815-385-6400
Fax Number	:	815-385-8127

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	J. SCOTT CAMPBELL
Credential	:
Telephone Number	:	815-385-6400

Provider Enumeration Date	:	05/10/2006
Last Update Date	:	05/03/2011

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