Basic Information
| Provider Information | |||||||||
| NPI: | 1104235415 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1001 E TOUHY AVE | ||||||||
| Address2: | SUITE# 170 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600185801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473901422 | ||||||||
| FaxNumber: | 8472973407 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610811203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156267333 | ||||||||
| FaxNumber: | 8156268752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2014 | ||||||||
| LastUpdateDate: | 08/12/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8476354600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149015740 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 149015740 | 01 | IL | STATE LICENSE | OTHER |