Provider Demographics
NPI:1225207921
Name:MILLER TWP C.C. SCHOOL #210
Entity Type:Organization
Organization Name:MILLER TWP C.C. SCHOOL #210
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-357-8151
Mailing Address - Street 1:3197 E 28TH RD
Mailing Address - Street 2:
Mailing Address - City:MARSEILLES
Mailing Address - State:IL
Mailing Address - Zip Code:61341-9567
Mailing Address - Country:US
Mailing Address - Phone:815-357-8151
Mailing Address - Fax:
Practice Address - Street 1:3197 E 28TH RD
Practice Address - Street 2:
Practice Address - City:MARSEILLES
Practice Address - State:IL
Practice Address - Zip Code:61341-9567
Practice Address - Country:US
Practice Address - Phone:815-357-8151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL022620089864431041S0200X
IL1600814235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid