Provider Demographics
NPI:1386854750
Name:ILLINOIS ALCOHOL AND DRUG EVALUATION SERVICE, INC
Entity type:Organization
Organization Name:ILLINOIS ALCOHOL AND DRUG EVALUATION SERVICE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:BAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-692-9236
Mailing Address - Street 1:7501 N UNIVERSITY ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1222
Mailing Address - Country:US
Mailing Address - Phone:309-692-9236
Mailing Address - Fax:309-692-5262
Practice Address - Street 1:7501 N UNIVERSITY ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1222
Practice Address - Country:US
Practice Address - Phone:309-692-9236
Practice Address - Fax:309-692-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA50140001A3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children