Provider Demographics
NPI:1194982025
Name:PROVENA ST MARYS HOSPITAL
Entity type:Organization
Organization Name:PROVENA ST MARYS HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EAP SUBSTANCE ABUSE COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW CADC
Authorized Official - Phone:815-937-2081
Mailing Address - Street 1:21 HERITAGE DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-937-2081
Mailing Address - Fax:815-937-8798
Practice Address - Street 1:21 HERITAGE DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-937-2081
Practice Address - Fax:815-937-8798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490064551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty