Provider Demographics
NPI: | 1639356017 |
---|---|
Name: | MOULTRIE COUNTY BEACON |
Entity Type: | Organization |
Organization Name: | MOULTRIE COUNTY BEACON |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DEVELOPMENTAL THERAPIST |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | LINDA |
Authorized Official - Middle Name: | KATHY |
Authorized Official - Last Name: | THOMAS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LT 81590803 P |
Authorized Official - Phone: | 217-728-7396 |
Mailing Address - Street 1: | 401 W WATER ST |
Mailing Address - Street 2: | |
Mailing Address - City: | SULLIVAN |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 61951-1883 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 217-728-7396 |
Mailing Address - Fax: | 217-728-2217 |
Practice Address - Street 1: | 401 W WATER ST |
Practice Address - Street 2: | |
Practice Address - City: | SULLIVAN |
Practice Address - State: | IL |
Practice Address - Zip Code: | 61951-1883 |
Practice Address - Country: | US |
Practice Address - Phone: | 217-728-7396 |
Practice Address - Fax: | 217-728-2217 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-01-28 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 001 | 251C00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251C00000X | Agencies | Day Training, Developmentally Disabled Services |