Provider Demographics
NPI:1578778403
Name:CENTRAL ILLINOIS DEVELOPMENTAL THERAPY, INC.
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS DEVELOPMENTAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:WINCHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-821-1752
Mailing Address - Street 1:PO BOX 1702
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-1702
Mailing Address - Country:US
Mailing Address - Phone:217-821-1752
Mailing Address - Fax:217-345-0910
Practice Address - Street 1:762 8TH ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2116
Practice Address - Country:US
Practice Address - Phone:217-821-1752
Practice Address - Fax:217-345-0910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336564313001Medicaid