Basic Information
| Provider Information | |||||||||
| NPI: | 1740774298 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CUNNINGHAM CHILDREN'S HOME OF URBANA IL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GIRLS GROUP HOME (BUILDING/PROGRAM) | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 N CUNNINGHAM AVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618021830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173673728 | ||||||||
| FaxNumber: | 2173672896 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 N CUNNINGHAM AVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618021830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173673728 | ||||||||
| FaxNumber: | 2173672896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2018 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
| AuthorizedOfficialMiddleName: | SUZETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF QUALITY IMPROVEMENT | ||||||||
| AuthorizedOfficialTelephone: | 2173673728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.