Healthcare Provider Details

I. General information

NPI: 1114861259
Provider Name (Legal Business Name): MARYVILLE ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 W DIVISION ST STE 407
CHICAGO IL
60651-3161
US

IV. Provider business mailing address

4909 W DIVISION ST STE 407
CHICAGO IL
60651-3161
US

V. Phone/Fax

Practice location:
  • Phone: 847-390-3004
  • Fax:
Mailing address:
  • Phone: 847-390-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: FREDERICK SMITH
Title or Position: ADMINISTRATOR OF COMMUNITY SERVICES
Credential:
Phone: 847-390-3004