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General NPI Number Information
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NPI Number | 1902007800
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Entity Type | Organization
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Legal Business Name | CORNELL INTERVENTIONS
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Dates
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Enumeration Date | 05/29/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 302 N 5TH ST
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62201-2913
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Country | US
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Telephone | 618-271-4542
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Fax |
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Provider Business Mailing Address
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Address Line | 302 N 5TH ST
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City | EAST SAINT LOUIS
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State | IL
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Zip | 62201-2913
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Country | US
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Telephone | 618-271-4542
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Fax |
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Authorized Official
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Title or Position | CONTRACT MGR
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Name | JEFF REAVY
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Credential |
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Telephone | 630-824-4547
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | A-8981-0017-A
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License Number State | IL
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