Healthcare Provider Details

I. General information

NPI: 1750658001
Provider Name (Legal Business Name): CUMBERLAND ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 COURTHOUSE SQUARE
TOLEDO IL
62468-9998
US

IV. Provider business mailing address

120 COURTHOUSE SQUARE PO BOX 385
TOLEDO IL
62468-9998
US

V. Phone/Fax

Practice location:
  • Phone: 217-849-3803
  • Fax: 217-849-3804
Mailing address:
  • Phone: 217-849-3803
  • Fax: 217-849-3804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1164633012
Identifier TypeMEDICAID
Identifier StateIL
Identifier Issuer

VIII. Authorized Official

Name: MS. DEBORAH A MATTHEW
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 217-849-3803