Healthcare Provider Details

I. General information

NPI: 1275771214
Provider Name (Legal Business Name): MARYVILLE ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 07/21/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 W BARTLETT RD
BARTLETT IL
60103-4479
US

IV. Provider business mailing address

1150 N RIVER RD
DES PLAINES IL
60016-1214
US

V. Phone/Fax

Practice location:
  • Phone: 630-736-7450
  • Fax:
Mailing address:
  • Phone: 847-294-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number008
License Number StateIL

VIII. Authorized Official

Name: NANCY Z WOULFE
Title or Position: DIRECTOR OF BUSINESS DEVELOPMENT
Credential:
Phone: 847-294-1910