Provider Demographics
NPI:1801252994
Name:SHELBY COUNTY COMMUNITY SERVICES INC
Entity type:Organization
Organization Name:SHELBY COUNTY COMMUNITY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLCLASURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-774-5587
Mailing Address - Street 1:1810 W SOUTH 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565-9595
Mailing Address - Country:US
Mailing Address - Phone:217-774-5587
Mailing Address - Fax:
Practice Address - Street 1:1810 W SOUTH 3RD ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-9595
Practice Address - Country:US
Practice Address - Phone:217-774-5587
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251C00000X
IL04121320800000X
IL199100020S320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04121Medicaid