Provider Demographics
NPI:1376635078
Name:ILLINI CHRISTIAN MINISTRIES INC
Entity Type:Organization
Organization Name:ILLINI CHRISTIAN MINISTRIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIR
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KIRKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:217-469-7566
Mailing Address - Street 1:PO BOX 200
Mailing Address - Street 2:204 N. MAIN SUITE 203
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:IL
Mailing Address - Zip Code:61873-0200
Mailing Address - Country:US
Mailing Address - Phone:217-469-7566
Mailing Address - Fax:217-469-2568
Practice Address - Street 1:204 N MAIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SAINT JOSEPH
Practice Address - State:IL
Practice Address - Zip Code:61873
Practice Address - Country:US
Practice Address - Phone:217-469-7566
Practice Address - Fax:217-469-2568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178003791103T00000X
IL180000680103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty