Provider Demographics
NPI:1487806436
Name:WESTERN ILLINOIS UNIVERSITY
Entity type:Organization
Organization Name:WESTERN ILLINOIS UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:309-298-1888
Mailing Address - Street 1:1 UNIVERSITY CIR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-1367
Mailing Address - Country:US
Mailing Address - Phone:309-298-1888
Mailing Address - Fax:309-298-2188
Practice Address - Street 1:1 UNIVERSITY CIR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-1367
Practice Address - Country:US
Practice Address - Phone:309-298-1888
Practice Address - Fax:309-298-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180000305251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health