Provider Demographics
NPI:1740543305
Name:THE OTHERSIDE A BEHAVIORAL HEALTHCARE CORP
Entity type:Organization
Organization Name:THE OTHERSIDE A BEHAVIORAL HEALTHCARE CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DEFORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-607-0098
Mailing Address - Street 1:1717 PHILO RD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-6044
Mailing Address - Country:US
Mailing Address - Phone:217-607-0098
Mailing Address - Fax:217-298-0142
Practice Address - Street 1:1717 PHILO RD
Practice Address - Street 2:SUITE 23
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-6044
Practice Address - Country:US
Practice Address - Phone:217-607-0098
Practice Address - Fax:217-298-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health