Basic Information
| Provider Information | |||||||||
| NPI: | 1104200237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E TOUHY AVE | ||||||||
| Address2: | SUITE 50 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600185801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476354600 | ||||||||
| FaxNumber: | 8476354764 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HANKES AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605051774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308962714 | ||||||||
| FaxNumber: | 6308965613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2015 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | STUTRUD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8476354600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 04092 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 04092 | 05 | IL | MEDICAID |