Provider Demographics
NPI:1912917725
Name:CISCO THERAPEUTIC SERVICES, INC.
Entity Type:Organization
Organization Name:CISCO THERAPEUTIC SERVICES, INC.
Other - Org Name:KRIS CISCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CISCO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:815-741-3009
Mailing Address - Street 1:1520 N ROCK RUN DR
Mailing Address - Street 2:SUITE 30A
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3153
Mailing Address - Country:US
Mailing Address - Phone:815-741-3009
Mailing Address - Fax:815-741-8322
Practice Address - Street 1:1520 N ROCK RUN DR
Practice Address - Street 2:SUITE 30A
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60435-3153
Practice Address - Country:US
Practice Address - Phone:815-741-3009
Practice Address - Fax:815-741-8322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932284OtherBCBS OF IL PROVIDER #