Provider Demographics
NPI:1811730492
Name:COUNTY OF HENRY
Entity type:Organization
Organization Name:COUNTY OF HENRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFOLLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-852-0197
Mailing Address - Street 1:110 N BURR BLVD
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-2214
Mailing Address - Country:US
Mailing Address - Phone:309-852-5272
Mailing Address - Fax:
Practice Address - Street 1:110 N BURR BLVD
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-2214
Practice Address - Country:US
Practice Address - Phone:309-852-5272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health