Healthcare Provider Details

I. General information

NPI: 1801447982
Provider Name (Legal Business Name): HUMAN SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 BRADFORD LN STE 2
WATERLOO IL
62298-3270
US

IV. Provider business mailing address

988 N ILLINOIS ROUTE 3
WATERLOO IL
62298-1059
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4444
  • Fax:
Mailing address:
  • Phone: 618-939-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MELISSA JONES
Title or Position: BUSINESS MANAGER
Credential:
Phone: 618-939-4444