Provider Demographics
NPI:1578266342
Name:SUPPORTED RESIDENTIAL
Entity Type:Organization
Organization Name:SUPPORTED RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON -MIDDLEBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-827-5351
Mailing Address - Street 1:710 W MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2868
Mailing Address - Country:US
Mailing Address - Phone:309-827-5351
Mailing Address - Fax:
Practice Address - Street 1:710 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-2868
Practice Address - Country:US
Practice Address - Phone:309-827-0067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MCLEAN CO CTR FOR HUMAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)