Organization
CENTRAL ILLINOIS DEVELOPMENTAL THERAPY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VIVIAN FAYE WINCHESTER (PRESIDENT)
(217) 821-1752
Entity
Organization
Contact information
Practice address
762 8TH ST, CHARLESTON, IL 61920-2116
(217) 821-1752
(217) 345-0910
Mailing address
PO BOX 1702, MATTOON, IL 61938-1702
(217) 821-1752
(217) 345-0910
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
336564313001
—
IL
Enumeration date
05/14/2007
Last updated
08/22/2020
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