Provider Demographics
NPI:1770618282
Name:COUNTRYSIDE ASSOCIATION FOR PEOPLE WITH DISABILITIES, INC.
Entity type:Organization
Organization Name:COUNTRYSIDE ASSOCIATION FOR PEOPLE WITH DISABILITIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KULICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-438-8855
Mailing Address - Street 1:21154 W SHIRLEY RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-2028
Mailing Address - Country:US
Mailing Address - Phone:847-438-8855
Mailing Address - Fax:847-438-9698
Practice Address - Street 1:21154 W SHIRLEY RD
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074-2028
Practice Address - Country:US
Practice Address - Phone:847-438-8855
Practice Address - Fax:847-438-9698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered251S00000XAgenciesCommunity/Behavioral Health