Basic Information
| Provider Information | |||||||||
| NPI: | 1578942108 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
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| OtherOrganizationName: | PRISONER & FAMILY MINISTRY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E TOUHY AVE | ||||||||
| Address2: | STE 170 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600185801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476354600 | ||||||||
| FaxNumber: | 8472973314 | ||||||||
| Practice Location | |||||||||
| Address1: | 1798 SUMMIT AVE | ||||||||
| Address2: | STE 104 | ||||||||
| City: | EAST SAINT LOUIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622052800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186043459 | ||||||||
| FaxNumber: | 6188759695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2015 | ||||||||
| LastUpdateDate: | 05/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | HAMBLET | ||||||||
| AuthorizedOfficialFirstName: | GREERANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8473901422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.