Basic Information
| Provider Information | |||||||||
| NPI: | 1871047209 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CUNNINGHAM CHILDREN'S HOME OF URBANA IL | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 701 DEVONSHIRE DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618207337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173673728 | ||||||||
| FaxNumber: | 2173672896 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 DEVONSHIRE DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618207337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173673728 | ||||||||
| FaxNumber: | 2173672896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2016 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIVINGSTON | ||||||||
| AuthorizedOfficialFirstName: | MARLIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / C.E.O. | ||||||||
| AuthorizedOfficialTelephone: | 2173673728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CUNNINGHAM CHILDREN'S HOME OF URBANA IL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW | ||||||||
| NPICertificationDate: | 06/08/2021 | ||||||||
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.