Basic Information
Provider Information | |||||||||
NPI: | 1205399524 | ||||||||
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 STE 170 | ||||||||
Address2: |   | ||||||||
City: | DES PLAINES | ||||||||
State: | IL | ||||||||
PostalCode: | 600185800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8473901422 | ||||||||
FaxNumber: | 8472973407 | ||||||||
Practice Location | |||||||||
Address1: | 940 W CULLOM AVE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606131619 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2242751978 | ||||||||
FaxNumber: | 8472973314 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/12/2019 | ||||||||
LastUpdateDate: | 04/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAMBLET | ||||||||
AuthorizedOfficialFirstName: | GREERANN | ||||||||
AuthorizedOfficialMiddleName: | LOVETTE | ||||||||
AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8473901422 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | A-0286-0031-A | 05 | IL |   | MEDICAID |