Provider Demographics
NPI:1184883779
Name:FRESH START BEHAVIORIAL CENTER
Entity type:Organization
Organization Name:FRESH START BEHAVIORIAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-757-2444
Mailing Address - Street 1:8 SURREY BROOK PLZ
Mailing Address - Street 2:
Mailing Address - City:SAUK VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60411-4913
Mailing Address - Country:US
Mailing Address - Phone:708-757-2444
Mailing Address - Fax:708-757-2449
Practice Address - Street 1:8 SURREY BROOK PLZ
Practice Address - Street 2:
Practice Address - City:SAUK VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60411-4913
Practice Address - Country:US
Practice Address - Phone:708-757-2444
Practice Address - Fax:708-757-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360933292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty