Healthcare Provider Details

I. General information

NPI: 1912917725
Provider Name (Legal Business Name): CISCO THERAPEUTIC SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N ROCK RUN DR SUITE 30A
CREST HILL IL
60435-3153
US

IV. Provider business mailing address

1520 N ROCK RUN DR SUITE 30A
CREST HILL IL
60435-3153
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-3009
  • Fax: 815-741-8322
Mailing address:
  • Phone: 815-741-3009
  • Fax: 815-741-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name: MS. KRIS CISCO
Title or Position: OWNER
Credential: LCSW
Phone: 815-741-3009