Provider Demographics
NPI:1346756491
Name:MAIN ST. PSYCHIATRY, S.C.
Entity type:Organization
Organization Name:MAIN ST. PSYCHIATRY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-526-3781
Mailing Address - Street 1:5911 NORTHWEST HWY STE 207
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8043
Mailing Address - Country:US
Mailing Address - Phone:815-526-3781
Mailing Address - Fax:815-526-3094
Practice Address - Street 1:10 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-2866
Practice Address - Country:US
Practice Address - Phone:815-526-3781
Practice Address - Fax:815-526-3094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-26
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-0862702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty