Healthcare Provider Details

I. General information

NPI: 1205295102
Provider Name (Legal Business Name): A STEP FORWARD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 E WILLIAM STREET RD
DECATUR IL
62521-1874
US

IV. Provider business mailing address

5310 E WILLIAM STREET RD
DECATUR IL
62521-1874
US

V. Phone/Fax

Practice location:
  • Phone: 217-422-6361
  • Fax:
Mailing address:
  • Phone: 217-422-6361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number201200009S
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number201200009S
License Number StateIL

VIII. Authorized Official

Name: MR. JEREMY RAY MAUPIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 217-422-6361