Provider Demographics
NPI:1245795251
Name:HUMAN SUPPORT SERVICES
Entity Type:Organization
Organization Name:HUMAN SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-939-4444
Mailing Address - Street 1:988 N ILLINOIS ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1059
Mailing Address - Country:US
Mailing Address - Phone:619-393-4444
Mailing Address - Fax:
Practice Address - Street 1:960 COLUMBIA CTR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-2545
Practice Address - Country:US
Practice Address - Phone:618-939-4444
Practice Address - Fax:618-939-4181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid