Provider Demographics
NPI:1477286516
Name:LOCUST STREET RESOURCE CENTER
Entity Type:Organization
Organization Name:LOCUST STREET RESOURCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-854-3166
Mailing Address - Street 1:320 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1648
Mailing Address - Country:US
Mailing Address - Phone:217-854-3166
Mailing Address - Fax:
Practice Address - Street 1:515 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1632
Practice Address - Country:US
Practice Address - Phone:217-854-3166
Practice Address - Fax:217-854-3778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness