=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659758043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL EAST ALCOHOLISM AND DRUG COUNCIL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2015
-----------------------------------------------------
Last Update Date | 10/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 726 4TH ST
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61920-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-348-8108
-----------------------------------------------------
Fax | 217-345-6794
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 635 DIVISION ST P.O. BOX 532
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61920-1902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-348-8108
-----------------------------------------------------
Fax | 217-345-6794
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | TERESSA M. PERDIEU
-----------------------------------------------------
Credential | MA CADC
-----------------------------------------------------
Telephone | 217-348-8108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | A-0631-0007-A
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------