Healthcare Provider Details

I. General information

NPI: 1700037876
Provider Name (Legal Business Name): FAMILY SUPPORT & TRAINING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 INTERSTATE DR
CHAMPAIGN IL
61822-1068
US

IV. Provider business mailing address

PO BOX 3486
CHAMPAIGN IL
61826-3486
US

V. Phone/Fax

Practice location:
  • Phone: 217-766-0492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JUANITA STANDIFER
Title or Position: CEO
Credential:
Phone: 217-766-0492