Basic Information
Provider Information | |||||||||
NPI: | 1265676597 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BEHAVIORAL HEALTH SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
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: | 8476354600 | ||||||||
FaxNumber: | 8472973407 | ||||||||
Practice Location | |||||||||
Address1: | 4840 W BYRON ST | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606412712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7732827800 | ||||||||
FaxNumber: | 7732822163 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/30/2009 | ||||||||
LastUpdateDate: | 04/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NOONAN | ||||||||
AuthorizedOfficialFirstName: | GERALD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8476354600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 036095776 | 05 | IL |   | MEDICAID | 036111400 | 05 | IL |   | MEDICAID | 036092099 | 05 | IL |   | MEDICAID | 036113899 | 05 | IL |   | MEDICAID | 036094832 | 05 | IL |   | MEDICAID | 036091774 | 05 | IL |   | MEDICAID | 036105330 | 05 | IL |   | MEDICAID |