Provider Demographics
NPI:1255977757
Name:IDJJ SD#428
Entity type:Organization
Organization Name:IDJJ SD#428
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPECIAL EDUCATION
Authorized Official - Prefix:
Authorized Official - First Name:BAMBI
Authorized Official - Middle Name:
Authorized Official - Last Name:BETHEL-LEITSCHUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-222-3148
Mailing Address - Street 1:1220 CENTREVILLE AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3089
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 CENTREVILLE AVE FL 2
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-3089
Practice Address - Country:US
Practice Address - Phone:618-222-3148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty