Provider Demographics
NPI:1255715280
Name:INTENSIVE OUT-PATIENT CARE
Entity type:Organization
Organization Name:INTENSIVE OUT-PATIENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:618-656-7064
Mailing Address - Street 1:2 CLUB CENTRE CT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3503
Mailing Address - Country:US
Mailing Address - Phone:618-656-7064
Mailing Address - Fax:618-656-9084
Practice Address - Street 1:2 CLUB CENTRE CT
Practice Address - Street 2:SUITE 1
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3503
Practice Address - Country:US
Practice Address - Phone:618-656-7064
Practice Address - Fax:618-656-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL371259842251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health