Provider Demographics
NPI:1164929055
Name:ITIC SUPPORT SERVICES INC
Entity Type:Organization
Organization Name:ITIC SUPPORT SERVICES INC
Other - Org Name:PREFERRED BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-238-5260
Mailing Address - Street 1:141 MARKET PL STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2034
Mailing Address - Country:US
Mailing Address - Phone:314-238-5260
Mailing Address - Fax:618-398-1759
Practice Address - Street 1:141 MARKET PL STE 100
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208
Practice Address - Country:US
Practice Address - Phone:618-398-4226
Practice Address - Fax:618-398-1759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1164929055Medicaid