Provider Demographics
NPI:1740774298
Name:CUNNINGHAM CHILDREN'S HOME OF URBANA IL
Entity Type:Organization
Organization Name:CUNNINGHAM CHILDREN'S HOME OF URBANA IL
Other - Org Name:GIRLS GROUP HOME (BUILDING/PROGRAM)
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF QUALITY IMPROVEMENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:SUZETTE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-367-3728
Mailing Address - Street 1:1301 N CUNNINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-1830
Mailing Address - Country:US
Mailing Address - Phone:217-367-3728
Mailing Address - Fax:217-367-2896
Practice Address - Street 1:1301 N CUNNINGHAM AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-1830
Practice Address - Country:US
Practice Address - Phone:217-367-3728
Practice Address - Fax:217-367-2896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid