1366957292 NPI number — MARYVILLE ACADEMY

Table of content: (NPI 1366957292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366957292 NPI number — MARYVILLE ACADEMY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYVILLE ACADEMY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY BEHAVIORAL HEALTH CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366957292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1455 E GOLF RD STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DES PLAINES
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60016-1254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-390-3004
Provider Business Mailing Address Fax Number:
847-390-3016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 N CLAREMONT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-1710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-491-3509
Provider Business Practice Location Address Fax Number:
312-391-3531
Provider Enumeration Date:
12/14/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WOULFE
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
Z
Authorized Official Title or Position:
DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official Telephone Number:
847-294-1910

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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