| Organization Name: | PROVENA ST MARYS HOSPITAL |
| NPI Number: | 1194982025 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BARRY S LEE (EAP SUBSTANCE ABUSE COUNSELOR) |
| Mailing Address: | 21 Heritage Drive Suite 102 Bourbonnais |
| State: | IL US |
| Postal Code: | 60914 |
| Phone Number: | 8159372081 |
| Fax Number: | 8159378798 |
| NPI Enumeration Date: | 05/19/2008 |
| NPI Last Update Date: | 05/19/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 149006455 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |