Basic Information
| Provider Information | |||||||||
| NPI: | 1013285220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RESURRECTION HEALTH CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RESURRECTION BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1414 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601603902 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1414 MAIN | ||||||||
| Address2: | |||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086810073 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2011 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NETHERLY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MYRON | ||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH TECHNICAN | ||||||||
| AuthorizedOfficialTelephone: | 7737595110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MSW,MA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.