Provider Demographics
NPI:1649519620
Name:GOOD SHEPHERD FOUNDATION OF HENRY COUNTY
Entity type:Organization
Organization Name:GOOD SHEPHERD FOUNDATION OF HENRY COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROESNER
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:309-944-6205
Mailing Address - Street 1:796 BOONE DR
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1783
Mailing Address - Country:US
Mailing Address - Phone:309-944-6205
Mailing Address - Fax:309-944-3258
Practice Address - Street 1:796 BOONE DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1783
Practice Address - Country:US
Practice Address - Phone:309-944-6205
Practice Address - Fax:309-944-3258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-9103-0002-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health