Healthcare Provider Details

I. General information

NPI: 1821136821
Provider Name (Legal Business Name): ILLINOIS DEPARTMENT OF HUMAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E JEFFERY ST
KANKAKEE IL
60901-5018
US

IV. Provider business mailing address

100 E JEFFERY ST
KANKAKEE IL
60901-5018
US

V. Phone/Fax

Practice location:
  • Phone: 815-939-8201
  • Fax: 815-939-8266
Mailing address:
  • Phone: 815-939-8201
  • Fax: 815-939-8266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number StateIL

VIII. Authorized Official

Name: DEBRA MUHLSTADT
Title or Position: FISCAL ADMINISTRATOR, SODC OPERATIO
Credential:
Phone: 815-288-8335