Provider Demographics
NPI:1265584155
Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Entity type:Organization
Organization Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL ADMINISTRATOR, SODC OPERATIO
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUHLSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-288-8335
Mailing Address - Street 1:134 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-1322
Mailing Address - Country:US
Mailing Address - Phone:815-584-3347
Mailing Address - Fax:
Practice Address - Street 1:134 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420-1322
Practice Address - Country:US
Practice Address - Phone:815-584-3347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-18
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL320600000X
315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities