Basic Information
| Provider Information | |||||||||
| NPI: | 1760157838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CUNNINGHAM CHILDREN'S HOME OF URBANA, IL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1301 N CUNNINGHAM AVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618021830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173673728 | ||||||||
| FaxNumber: | 2173672896 | ||||||||
| Practice Location | |||||||||
| Address1: | 1204 N DIVISION AVE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618011870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173379057 | ||||||||
| FaxNumber: | 2173675910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2021 | ||||||||
| LastUpdateDate: | 08/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | SHAWN | ||||||||
| AuthorizedOfficialMiddleName: | SUZETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF QUALITY IMPROVEMENT | ||||||||
| AuthorizedOfficialTelephone: | 2173673728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | N | Agencies | Voluntary or Charitable | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.