Provider Demographics
NPI:1821440868
Name:LOCUST STREET RESOURCE CENTER CILA #2
Entity Type:Organization
Organization Name:LOCUST STREET RESOURCE CENTER CILA #2
Other - Org Name:MACOUPIN COUNTY MENTAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-854-3166
Mailing Address - Street 1:320 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1648
Mailing Address - Country:US
Mailing Address - Phone:217-854-3166
Mailing Address - Fax:217-854-9729
Practice Address - Street 1:202 E 3RD NORTH ST
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:IL
Practice Address - Zip Code:62069-1320
Practice Address - Country:US
Practice Address - Phone:217-854-3166
Practice Address - Fax:217-854-9729
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOCUST STREET RESOURCE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)