Provider Demographics
NPI:1184154007
Name:FAMILY SERVICE AGENCY OF DEKALB COUNTY, INC.
Entity type:Organization
Organization Name:FAMILY SERVICE AGENCY OF DEKALB COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TYNISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-758-8616
Mailing Address - Street 1:1325 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2483
Mailing Address - Country:US
Mailing Address - Phone:815-758-8616
Mailing Address - Fax:
Practice Address - Street 1:1325 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2483
Practice Address - Country:US
Practice Address - Phone:815-758-8616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17004261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL17004Medicaid