=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154848216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S HOME ASSOCIATION OF ILLINOIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2017
-----------------------------------------------------
Last Update Date | 04/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7225 W PLANK RD
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61604-5252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-687-7241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2130 N KNOXVILLE AVE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61603-2460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF COMPLIANCE
-----------------------------------------------------
Name | JULIE SIEBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-687-7440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | A-6162-0001-A
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------