Healthcare Provider Details

I. General information

NPI: 1164612065
Provider Name (Legal Business Name): CHILDREN'S CENTER FOR BEHAVIORAL DEVELOPEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 N 88TH ST HIGHWAY 157 SOUTH
CENTREVILLE IL
62203-2705
US

IV. Provider business mailing address

353 N 88TH ST HIGHWAY 157 SOUTH
CENTREVILLE IL
62203-2705
US

V. Phone/Fax

Practice location:
  • Phone: 618-398-1152
  • Fax: 618-398-6977
Mailing address:
  • Phone: 618-398-1152
  • Fax: 618-398-6977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateIL

VIII. Authorized Official

Name: RAYMOND C. AMRHEIN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 618-398-1152