Basic Information
| Provider Information | |||||||||
| NPI: | 1235741745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E TOUHY AVE STE 50 | ||||||||
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| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600185817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473901422 | ||||||||
| FaxNumber: | 8472973407 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 E DEYOUNG ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629592724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189979076 | ||||||||
| FaxNumber: | 6189980604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2020 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | STUTRUD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8476354600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.