Healthcare Provider Details

I. General information

NPI: 1104146802
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICE OF IL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S DAMEN AVE STE 205
CHICAGO IL
60608-1170
US

IV. Provider business mailing address

1001 E TOUHY AVE SUITE 50
DES PLAINES IL
60018-5801
US

V. Phone/Fax

Practice location:
  • Phone: 312-949-4340
  • Fax: 312-243-1866
Mailing address:
  • Phone: 847-635-4600
  • Fax: 847-635-6764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number04092
License Number StateIL

VIII. Authorized Official

Name: MR. MARK STUTRUD
Title or Position: PRESIDENT
Credential:
Phone: 847-635-4600