Basic Information
| Provider Information | |||||||||
| NPI: | 1740453125 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
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| OtherOrganizationName: | WASHINGTON PRADER WILLI GROUP HOME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| 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: | 612 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BEARDSTOWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 626181541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173235367 | ||||||||
| FaxNumber: | 2173234559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 04/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | NOONAN | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8476354600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | 926169 | IL | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 926129 | 01 | IL | DEPT OF HUMAN SERVICES | OTHER |