Basic Information
Provider Information
NPI: 1154890721
EntityType: 2
ReplacementNPI:  
OrganizationName: LUTHERAN SOCIAL SERVICES OF ILLINOIS
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Mailing Information
Address1: 1001 E TOUHY AVE STE 170
Address2:  
City: DES PLAINES
State: IL
PostalCode: 600185800
CountryCode: US
TelephoneNumber: 8473904422
FaxNumber: 8472973314
Practice Location
Address1: 1550 S ALBANY AVE
Address2:  
City: CHICAGO
State: IL
PostalCode: 606232212
CountryCode: US
TelephoneNumber: 2242751978
FaxNumber: 8472973314
Other Information
ProviderEnumerationDate: 11/13/2018
LastUpdateDate: 11/13/2018
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: HAMBLET
AuthorizedOfficialFirstName: GREERANN
AuthorizedOfficialMiddleName: LOVETTE
AuthorizedOfficialTitleorPosition: BUSINESS MANAGER
AuthorizedOfficialTelephone: 8473904422
IsSoleProprietor:  
IsOrganizationSubpart: N
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QR0405X  Y Ambulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder

ID Information
IDTypeStateIssuerDescription
A-02860029-A05IL MEDICAID


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