You must submit the following documents:

You are required to obtain a National Provider Identification Number (NPI) to render services.

Please see web site on National Provider Identification Number

Send the completed documents to the address below:

Department of Human Services
Division of Developmental Disabilities
319 E. Madison Street, Suite 3M
Springfield, IL 62701
Fax:  (217) 558-2799

Attention:  Provider Enrollment

Important Resources for Program Requirements