Organization
IDJJ SD#428
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BAMBI BETHEL-LEITSCHUH (DIRECTOR OF SPECIAL EDUCATION)
(618) 222-3148
Entity
Organization
Contact information
Practice address
1220 CENTREVILLE AVE FL 2, BELLEVILLE, IL 62220-3089
(618) 222-3148
Mailing address
1220 CENTREVILLE AVE FL 2, BELLEVILLE, IL 62220-3089
Taxonomy
Speciality
Code
Description
License number
State
103TS0200X
School Psychologist
Primary
—
—
Other
Enumeration date
11/20/2019
Last updated
11/20/2019
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