Provider Demographics
NPI:1598912149
Name:MCHENRY COUNTY MENTAL HEALTH BOARD
Entity Type:Organization
Organization Name:MCHENRY COUNTY MENTAL HEALTH BOARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALEXANDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-455-2828
Mailing Address - Street 1:620 DAKOTA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3732
Mailing Address - Country:US
Mailing Address - Phone:715-455-2828
Mailing Address - Fax:
Practice Address - Street 1:5320 W ELM ST
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4029
Practice Address - Country:US
Practice Address - Phone:815-788-4360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF MCHENRY ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-26
Last Update Date:2010-08-12
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
IL009Medicaid