Healthcare Provider Details

I. General information

NPI: 1073960167
Provider Name (Legal Business Name): ASSOCIATION FOR INDIVIDUAL DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 NEW INDIAN TRAIL CT.
AURORA IL
60506-2494
US

IV. Provider business mailing address

309 NEW INDIAN TRAIL CT.
AURORA IL
60506-2494
US

V. Phone/Fax

Practice location:
  • Phone: 630-966-4000
  • Fax: 630-844-2065
Mailing address:
  • Phone: 630-966-4000
  • Fax: 630-844-2065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: LYNN O'SHEA
Title or Position: PRESIDENT
Credential:
Phone: 630-966-4001