Healthcare Provider Details

I. General information

NPI: 1801252994
Provider Name (Legal Business Name): SHELBY COUNTY COMMUNITY SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 W SOUTH 3RD ST
SHELBYVILLE IL
62565-9595
US

IV. Provider business mailing address

1810 W SOUTH 3RD ST
SHELBYVILLE IL
62565-9595
US

V. Phone/Fax

Practice location:
  • Phone: 217-774-5587
  • Fax:
Mailing address:
  • Phone: 217-774-5587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number04121
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number199100020S
License Number StateIL

VIII. Authorized Official

Name: THOMAS COLCLASURE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 217-774-5587