Basic Information
| Provider Information | |||||||||
| NPI: | 1730576596 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ECKER CENTER FOR BEHAVIORAL HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ECKER CENTER FOR MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1845 GRANDSTAND PL | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601236603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476950484 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 409 ILLINOIS AVE UNIT 1A | ||||||||
| Address2: | |||||||||
| City: | ST CHARLES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601742966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303775200 | ||||||||
| FaxNumber: | 6305136892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2015 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROCHFORT | ||||||||
| AuthorizedOfficialFirstName: | PAULINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8476950484 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 04050 | 05 | IL | MEDICAID |