Provider Demographics
NPI:1437586112
Name:HUMAN SUPPORT SERVICES
Entity Type:Organization
Organization Name:HUMAN SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-939-4444
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-0146
Mailing Address - Country:US
Mailing Address - Phone:618-939-4444
Mailing Address - Fax:618-939-4181
Practice Address - Street 1:224 N MAIN ST REAR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1264
Practice Address - Country:US
Practice Address - Phone:618-939-4444
Practice Address - Fax:618-939-4181
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUMAN SUPPORT SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06715560OtherBCBS
MO10B862OtherBCBS
IL06715560OtherBCBS
IL714580Medicare PIN