=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427069145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISABILITY MANAGEMENT NETWORK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6723 WEAVER RD. STE. 108
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61114-8052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-633-0880
-----------------------------------------------------
Fax | 815-633-4740
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6723 WEAVER RD SUITE 108
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61114-8052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-633-0880
-----------------------------------------------------
Fax | 815-633-4740
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | R.N.
-----------------------------------------------------
Name | MRS. CONSTANCE SUE MARA
-----------------------------------------------------
Credential | C.O.H.N.-S, C.C.M.
-----------------------------------------------------
Telephone | 815-262-0442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------