Healthcare Provider Details

I. General information

NPI: 1124401179
Provider Name (Legal Business Name): OMNI YOUTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W LAKE COOK RD
BUFFALO GROVE IL
60689
US

IV. Provider business mailing address

1111 W LAKE COOK RD
BUFFALO GROVE IL
60689
US

V. Phone/Fax

Practice location:
  • Phone: 847-353-1500
  • Fax: 847-465-1964
Mailing address:
  • Phone: 847-353-1500
  • Fax: 847-465-1964

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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SHANAN MATTHEW EGGER
Title or Position: CFO
Credential: CFO
Phone: 847-353-1762