Provider Demographics
NPI:1073966719
Name:FOREST CITY BEHAVIOR LLC
Entity Type:Organization
Organization Name:FOREST CITY BEHAVIOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:815-627-0641
Mailing Address - Street 1:807 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-1662
Mailing Address - Country:US
Mailing Address - Phone:815-627-0641
Mailing Address - Fax:270-514-8294
Practice Address - Street 1:807 MONROE ST
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-1662
Practice Address - Country:US
Practice Address - Phone:815-627-0641
Practice Address - Fax:270-514-8294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
IL071-007297103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty