Basic Information
| Provider Information | |||||||||
| NPI: | 1619124302 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY ELEMENTS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALNUT OFFICE LOCATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 FOX DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618207236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173988080 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 N WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173988080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2008 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERGUSON | ||||||||
| AuthorizedOfficialFirstName: | SHEILA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXEC OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2173988080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY ELEMENTS, INC | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1831167337 | 01 | BLUE CROSS | OTHER | 1831167337 | 01 | TRICARE | OTHER |