Provider Demographics
NPI:1801993142
Name:THE ANTIOCH GROUP, INC.
Entity type:Organization
Organization Name:THE ANTIOCH GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-692-6622
Mailing Address - Street 1:6615 N. BIG HOLLOW RD.
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2451
Mailing Address - Country:US
Mailing Address - Phone:309-692-6622
Mailing Address - Fax:
Practice Address - Street 1:6615 N. BIG HOLLOW RD.
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2451
Practice Address - Country:US
Practice Address - Phone:309-692-6622
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004483103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL597850Medicare ID - Type UnspecifiedLCSW
IL394140Medicare ID - Type UnspecifiedPSYCHOLOGISTS