1306834726 NPI number — ILLINOIS DEPARTMENT OF HUMAN SERVICES

Table of content: MRS. KELLEY DAWN FAKO ATC (NPI 1093858532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306834726 NPI number — ILLINOIS DEPARTMENT OF HUMAN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS DEPARTMENT OF HUMAN SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306834726
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31
Provider Second Line Business Mailing Address:
1315 LEHMEN DR CHESTER MENTAL HEALTH CENTER
Provider Business Mailing Address City Name:
CHESTER
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62233-0031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-826-4571
Provider Business Mailing Address Fax Number:
618-826-3229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 LEHMEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62233-2542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-826-4571
Provider Business Practice Location Address Fax Number:
618-826-3229
Provider Enumeration Date:
10/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ZIMMER
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
REIMBURSEMENT OFFICE II SUPERVISOR
Authorized Official Telephone Number:
618-826-4571

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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