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General NPI Number Information
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NPI Number | 1811284565
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Entity Type | Organization
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Legal Business Name | GROW IN ILLINOIS
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Dates
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Enumeration Date | 07/01/2011
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Last Update Date | 07/01/2011
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Provider Practice Location Address
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Address Line | 223 MOHAWK DR
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City | BOURBONNAIS
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State | IL
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Zip | 60914-1351
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Country | US
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Telephone | 815-933-6690
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Fax | 815-933-9937
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Provider Business Mailing Address
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Address Line | 1108 E COURT ST
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City | KANKAKEE
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State | IL
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Zip | 60901-4257
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Country | US
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Telephone | 815-933-6690
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Fax | 815-933-9937
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Authorized Official
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Title or Position | RESIDENTIAL COORDINATOR
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Name | MS. DIANNE MAXWELL
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Credential |
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Telephone | 815-933-6690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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