Basic Information
| Provider Information | |||||||||
| NPI: | 1659974913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAYFIELD | ||||||||
| FirstName: | ADAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WEST FRANKFORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628962210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189376483 | ||||||||
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| Practice Location | |||||||||
| Address1: | CENTERSTONE OF ILLINOIS INC | ||||||||
| Address2: | 202 SOUTH BENTLEY | ||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556083560 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2020 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | IL | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | IL2970 | 05 | IL | MEDICAID |