Basic Information
| Provider Information | |||||||||
| NPI: | 1811175532 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ECKER CENTER FOR BEHAVIORAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ECKER CENTER FOR MENTAL HEALTH | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1845 GRANDSTAND PL | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601236603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476950484 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1535 BURGUNDY PKWY | ||||||||
| Address2: | |||||||||
| City: | STREAMWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601071811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308376445 | ||||||||
| FaxNumber: | 6308376901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROCHFORT | ||||||||
| AuthorizedOfficialFirstName: | PAULINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8476950484 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| 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 |