Provider Demographics
NPI:1598717597
Name:INDEPENDENCE HEALTH & THERAPY
Entity Type:Organization
Organization Name:INDEPENDENCE HEALTH & THERAPY
Other - Org Name:FAMILY ALLIANCE INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-338-3590
Mailing Address - Street 1:2028 N SEMINARY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2626
Mailing Address - Country:US
Mailing Address - Phone:815-338-3590
Mailing Address - Fax:815-337-4406
Practice Address - Street 1:2028 N SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2626
Practice Address - Country:US
Practice Address - Phone:815-338-3590
Practice Address - Fax:815-337-4406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
IL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6009801Medicaid
IL994280Medicare PIN