Provider Demographics
NPI:1457734469
Name:VA ILLIANA HEALTHCARE SYSTEM
Entity type:Organization
Organization Name:VA ILLIANA HEALTHCARE SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRYANNA
Authorized Official - Middle Name:ELYCE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:217-554-3755
Mailing Address - Street 1:6 HEDGE CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-2015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 E MAIN ST
Practice Address - Street 2:MAIL SLOT 122
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5117
Practice Address - Country:US
Practice Address - Phone:217-554-3755
Practice Address - Fax:217-554-4813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6906-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty