Provider Demographics
NPI:1942485230
Name:GROW IN ILLINOIS
Entity Type:Organization
Organization Name:GROW IN ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-352-6989
Mailing Address - Street 1:2403 W SPRINGFIELD AVE
Mailing Address - Street 2:PO BOX 3667
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2883
Mailing Address - Country:US
Mailing Address - Phone:217-352-6989
Mailing Address - Fax:217-352-8530
Practice Address - Street 1:1108 E COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-4257
Practice Address - Country:US
Practice Address - Phone:815-933-6690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL05005320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness