Provider Demographics
NPI:1558456210
Name:LOCUST STREET RESOURCE CENTER
Entity Type:Organization
Organization Name:LOCUST STREET RESOURCE CENTER
Other - Org Name:MACOUPIN COUNTY MENTAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KILBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:217-854-3166
Mailing Address - Street 1:320 SOUTH LOCUST STREET
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626
Mailing Address - Country:US
Mailing Address - Phone:217-854-3166
Mailing Address - Fax:217-854-9729
Practice Address - Street 1:320 SOUTH LOCUST STREET
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626
Practice Address - Country:US
Practice Address - Phone:217-854-3166
Practice Address - Fax:217-854-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL757620Medicare ID - Type Unspecified