Provider Demographics
NPI:1629328802
Name:CHRISTIAN SOCIAL SERVICES OF ILLINOIS
Entity Type:Organization
Organization Name:CHRISTIAN SOCIAL SERVICES OF ILLINOIS
Other - Org Name:CATHOLIC SOCIAL SERVICES OF SOUTHERN IL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ASSOCIATE EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:G
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:618-688-1161
Mailing Address - Street 1:219 WITHERS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8273
Mailing Address - Country:US
Mailing Address - Phone:618-244-0344
Mailing Address - Fax:618-244-1455
Practice Address - Street 1:219 WITHERS DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-8273
Practice Address - Country:US
Practice Address - Phone:618-244-0344
Practice Address - Fax:618-244-1455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL003976-12253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1598031700Medicaid
IL1861758575Medicaid