Basic Information
| Provider Information | |||||||||
| NPI: | 1568518496 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FELLOWSHIP HOUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 N MAIN ST | ||||||||
| Address2: | P.O. BOX 682 | ||||||||
| City: | ANNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629061665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188334456 | ||||||||
| FaxNumber: | 6188332371 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629061665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6188334456 | ||||||||
| FaxNumber: | 6188332371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FINCH | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
| AuthorizedOfficialMiddleName: | RAE | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6188334456 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.S. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | A-0626-0002-A | IL | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.