Provider Demographics
NPI:1568518496
Name:FELLOWSHIP HOUSE
Entity Type:Organization
Organization Name:FELLOWSHIP HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:FINCH
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:618-833-4456
Mailing Address - Street 1:800 N MAIN ST
Mailing Address - Street 2:P.O. BOX 682
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1665
Mailing Address - Country:US
Mailing Address - Phone:618-833-4456
Mailing Address - Fax:618-833-2371
Practice Address - Street 1:800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1665
Practice Address - Country:US
Practice Address - Phone:618-833-4456
Practice Address - Fax:618-833-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0626-0002-A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid