Basic Information
| Provider Information | |||||||||
| NPI: | 1063005288 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPRINGHEALTH BEHAVIORAL HEALTH AND INTEGRATED CARE ILLINOIS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 N WHITTINGTON PKWY | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402227101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3921 PINTAIL DR STE B | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627116738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178430290 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2021 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | MATTINGLY | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MGR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5026307425 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.