Provider Demographics
NPI:1518239706
Name:RESURRECTION HEALTH CARE
Entity Type:Organization
Organization Name:RESURRECTION HEALTH CARE
Other - Org Name:RESURRECTION BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BEHAVIORAL HEALTH TECHNICAM
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MYRON
Authorized Official - Last Name:NETHERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, MA, MS
Authorized Official - Phone:773-567-5110
Mailing Address - Street 1:1414 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1414 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3902
Practice Address - Country:US
Practice Address - Phone:708-881-0073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM0801X320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness