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Organization
ITIC SUPPORT SERVICES GROUP LLC
Active
Organization
ITIC SUPPORT SERVICES GROUP LLC
Active
Parent organization
ITIC SUPPORT SERVICES INC
Other names
PREFERRED BEHAVIORAL HEALTH, ITIC Support Services
Organization subpart
Yes
Provider details
NPI number
Legal business name
ITIC SUPPORT SERVICES INC
Authorized official
MR. RYAN W MORRIS (REGISTER AGENT)
(314) 238-5260
Entity
Organization
Contact information
Practice address
141 MARKET PL, FAIRVIEW HEIGHTS, IL 62208-2034
(314) 238-5260
Mailing address
141 MARKET PL, FAIRVIEW HEIGHTS, IL 62208-2034
(314) 238-5260
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
—
2084P0800X
Psychiatry Physician
—
—
363LF0000X
Family Nurse Practitioner
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1164929055
—
IL
Enumeration date
12/07/2018
Last updated
08/27/2019
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