Healthcare Provider Details

I. General information

NPI: 1174554331
Provider Name (Legal Business Name): THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 W ROOSEVELT RD
CHICAGO IL
60608-1336
US

IV. Provider business mailing address

808 S WOOD ST STE 169
CHICAGO IL
60612-7306
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-6695
  • Fax: 312-413-0086
Mailing address:
  • Phone: 312-996-6695
  • Fax: 312-413-0086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY THERESE KEEHN
Title or Position: ASSOC DEAN FOR CLINICAL AFFAIRS
Credential: PT
Phone: 312-413-2873