Provider Demographics
NPI:1063544401
Name:STARVED ROCK REGIONAL CENTER FOR THERAPY & CHILD DEVELOPMENT
Entity type:Organization
Organization Name:STARVED ROCK REGIONAL CENTER FOR THERAPY & CHILD DEVELOPMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-434-0857
Mailing Address - Street 1:1013 ADAMS STREET
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61354-4304
Mailing Address - Country:US
Mailing Address - Phone:815-434-0857
Mailing Address - Fax:815-434-2260
Practice Address - Street 1:1013 ADAMS STREET
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61354-4304
Practice Address - Country:US
Practice Address - Phone:815-434-0857
Practice Address - Fax:815-434-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2081P0010X, 225X00000X, 235Z00000X, 251V00000X
251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251V00000XAgenciesVoluntary or Charitable
No2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5015093OtherBCBS