Provider Demographics
NPI:1306203856
Name:DEKALB BEHAVIORAL HEALTH FOUNDATION, INC.
Entity Type:Organization
Organization Name:DEKALB BEHAVIORAL HEALTH FOUNDATION, INC.
Other - Org Name:NORTHWESTERN MEDICINE BEN GORDON CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZYDEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-748-2986
Mailing Address - Street 1:PO BOX 1109
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-7109
Mailing Address - Country:US
Mailing Address - Phone:815-756-8501
Mailing Address - Fax:
Practice Address - Street 1:631 S 1ST ST
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-756-8501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEKALB BEHAVIORAL HEALTH FOUNDATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-27
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-5202-0001-A261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100268864Medicare PIN