| NPI | 1124617311 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DAVID HICKS State Director 815-543-5926 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QD1600X Clinic/Center, Developmental Disabilities |
| Enumeration Date | 2021-01-13 |
| Last Update Date | 2021-01-13 |