| Supported Residential | |
|
710 W Mulberry St Bloomington IL 61701-2868 | |
| (309) 827-0067 | |
| Not Available |
| Full Name | Supported Residential |
|---|---|
| Speciality | Clinic/center - Mental Health (including Community Mental Health Center) |
| Location | 710 W Mulberry St, Bloomington, Illinois |
| Authorized Official Name and Position | June Peterson -middlebrooks (ACCOUNTS RECEIVABLE) |
| Authorized Official Contact | 3098275351 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Supported Residential 710 W Mulberry St Bloomington IL 61701-2868 Ph: (309) 827-5351 | Supported Residential 710 W Mulberry St Bloomington IL 61701-2868 Ph: (309) 827-0067 |
| NPI Number | 1578266342 |
|---|---|
| Provider Enumeration Date | 03/22/2023 |
| Last Update Date | 03/22/2023 |
| Certification Date | 03/22/2023 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1578266342 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
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