MEDICARE: CATHOLIC CHARITIES OF THE DIOCESE OF PEORIA

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility		IL
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1891942785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CATHOLIC CHARITIES OF THE DIOCESE OF PEORIA

Provider Business Mailing Address
First Line	:	419 NE MADISON AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61603-3719
Country	:	US
Telephone Number	:	309-636-8012
Fax Number	:	309-674-1664

Provider Business Practice Location Address
First Line	:	419 NE MADISON AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61603-3719
Country	:	US
Telephone Number	:	309-636-8012
Fax Number	:	309-674-1664

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. PATRICIA FOX
Credential	:
Telephone Number	:	309-636-8012

Provider Enumeration Date	:	08/21/2008
Last Update Date	:	01/27/2011

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Directions to “CATHOLIC CHARITIES OF THE DIOCESE OF PEORIA ” Practice Location

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