Healthcare Provider Details

I. General information

NPI: 1720203326
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 N AVONDALE AVE SUITE A 101
CHICAGO IL
60631-1900
US

IV. Provider business mailing address

1001 E TOUHY AVE SUITE 170
DES PLAINES IL
60018-5801
US

V. Phone/Fax

Practice location:
  • Phone: 773-774-7555
  • Fax: 773-774-8910
Mailing address:
  • Phone: 847-635-4600
  • Fax: 847-297-3407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GERALD NOONAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 847-635-4600